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Pacific Ketamine Institute Notice of Privacy Practices

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect immediately and will remain in effect until we replace it.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION. PLEASE REVIEW IT CAREFULLY.

Pacific Ketamine Institute (“PKI”) is committed to protecting the confidentiality of its patients’ medical information. This Notice describes how PKI may use your medical information within PKI, and how we may disclose it to others outside of PKI. This Notice also describes your rights concerning your own medical information. Please review it carefully and let us know if you have questions.

HOW WILL WE USE AND DISCLOSE YOUR MEDICAL INFORMATION?

Treatment : PKI may use your medical information to provide you with medical services and supplies. PKI may also disclose your medical information to others who need that information to treat you. This may include but is not limited to doctors, physician assistants, nurses and medical transportation providers, as well as others involved in your care, as deemed medically appropriate. For example – your physician will be allowed to have access to your PKI medical record to assist in your follow-up care. PKI may also use your medical information to contact you to remind you of an upcoming appointment, to inform you about possible treatment options or alternatives, or to advise you about health-related services available to you.

Family Members and Others Involved in Your Care :

PKI may disclose your medical information to a family member or friend who is involved in your medical care, or to someone who helps to pay for your care. If you do not want PKI to disclose your medical information to family members or others, please inform PKI staff members assigned to your care. You may modify this list at any time.

Payment : PKI may use and disclose your medical information to secure payment for the medical services and supplies provided to you. For example – your health plan or health insurance company may ask to see parts of your medical record before they will pay PKI for your treatment.

Healthcare Operations : PKI may use and disclose your medical information if it is necessary to improve the quality of care provided to patients or to run PKI. Your medical information may be used to conduct quality improvement activities, to obtain audit, accounting or legal services, or to conduct business management and planning. For example – PKI staff members may look at your medical record to evaluate whether PKI personnel, your doctors, or other health care professionals did a good job.

Research : PKI may use or disclose your medical information for research projects, such as studying the effectiveness of a treatment you received. These research projects must go through a special process that protects the confidentiality of your medical information.

Required by Law : Federal, state or local laws may require PKI to disclose patients’ medicalinformation.

Public Health : PKI may report certain medical information for public health purposes. PKI also may need to report patient problems with medications or medical products to the Food and Drug Administration (“FDA”), or may notify patients of recalls of products they are using.

Public Safety : PKI may disclose medical information for public safety purposes in limited circumstances. We may disclose medical information to law enforcement officials in response to a search warrant, or a grand jury subpoena. We also may disclose medical information to assist law enforcement officials in identifying or locating a person, to prosecute a crime of violence, to report deaths that may have resulted from criminal conduct, or to report criminal conduct at PKI. We may disclose your medical information to law enforcement officials and others to prevent a serious threat to health or safety of thecommunity or an individual.

Health Oversight Activities : Pacific Ketamine Institute may disclose medical information to a government agency that oversees PKI or its personnel, and requires medical information to monitor PKI’s compliance with state and federal laws.

Military, Veterans, National Security and Other Government Purposes : If you are a member of the armed forces, PKI may release your medical information as required by military command authorities or to the Department of Veterans Affairs. PKI may also disclose medical information to federal officials for intelligence and national security purposes or for presidential protective services.

Judicial and Administrative Proceedings : PKI may disclose medical information in any judicial or administrative proceeding if ordered to do so by a court, or if PKI receives a subpoena or a search warrant. You will receive advance notice about this disclosure in most situations, so that you will have a chance to object to sharing your medical information.

Information with Additional Protection : Certain types of medical information have additional protection under state or federal law. Medical information about evaluation and treatment for a serious mental illness is treated differently than other types of information. PKI is required to get your permission before disclosing that information to others in many circumstances.

Disclosure Accounting : You have the right to receive a list of instances in which we, or our business associates, disclosed your health information for purposes other than treatment, payment, healthcare operations and/or certain other activities. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Other Uses and Disclosures : If PKI wishes to use or disclose your medical information for a purpose that is not discussed in this Notice. PKI will seek your permission. Permission granted to PKI may be rescinded at any time, unless PKI has already acted on your permission to use or disclose the information. To revoke your permission, please notify PKI
in writing at: hello@pacificketamine.com.

WHAT ARE YOUR RIGHTS?

Right to Request Your Medical Information : Patients have a right to look at their own medical information and to get a copy of that information. The law requires PKI to keep the original record. This includes your medical record, your billing record, and other records we use to make decisions about your care. Medical information that is available electronically may be obtained in that format.

If you request a copy of your information, you will be charged for PKI’s costs to copy the information. You will be notified in advance what this copying will cost. Patients can view their record at no cost.

Right to Request Amendment of Medical Information You Believe is Erroneous or Incomplete : If you examine your medical information and believe that some of the information is wrong or incomplete, you may ask us to amend your record.

Right to Obtain a List of Certain Disclosures of Your Medical Information : You have the right to request a list of many of the disclosures PKI makes of your medical information.

To receive a list, please contact PKI. The first list will be provided to you free of charge, but you may be charged a fee for any additional lists requested during the same year. You will be notified in advance what this list will cost.

Right to Request Restrictions on How PKI Will Use or Disclose Your Medical Information for Treatment, Payment or Health Care Operations : You have the right to ask PKI not to make use or disclosure of your medical information to treat you, to seek payment for care, or to operate PKI. You may require a restriction on the disclosure of your medical information to a health plan, where that information is associated with an item or service for which you paid out-of-pocket. Otherwise, PKI is not required to agree to your request. If we do agree, we will comply with that agreement. To request a restriction, please contact PKI and describe your request in detail.

Right to Request Confidential Communication : You have the right to ask PKI to communicate with you in a way that you will feel is more confidential. For example – you can ask us not to call your home, but to communicate only by mail. At the time of admission or upon registration, you may orally request confidential communications. Otherwise, you must submit a request in writing. You have the right to ask to speak with your health care providers in private, outside the presence of others.

Amendment : You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

Right to a Paper Copy : If you have received this Notice electronically, you have the right to a paper copy at any time. You may download a paper copy of the Notice from our website, or you may obtain a paper copy of the Notice at any PKI facility.

CHANGES TO THIS NOTICE

From time to time, PKI may change its practices concerning how it uses or discloses patient medical information, or how PKI will implement patient rights concerning their information. PKI reserves the right to change this Notice and to make the provisions in our new notice effective for all medical information we maintain. A revised Notice of Privacy Practices will be published for any further changes to these practices. Copies of PKI’s current Notice of Privacy Practices may be obtained by contacting PKI or by visiting our website

HEALTH CARE PROVIDERS COVERED BY THIS NOTICE

This Notice of Privacy Practices applies to PKI and its personnel. PKI may share your information with other providers for treatment purposes, to be reimbursed for treatment, or to conduct health care operations. These health care providers will follow this Notice for information they receive about you from PKI. Other health care providers may follow different practices at their own offices or facilities.

CONCERNS OR COMPLAINTS

Please tell us about any problems or concerns you have with your privacy rights, or how PKI uses or discloses your medical information. If you have a concern, please contact PKI at: hello@pacificketamine.com or call 424-332-5550.

If PKI cannot resolve your concern, you may also file a complaint with the federal government. We will not penalize you or retaliate against you in any way, for the filing of a complaint.

IF YOU HAVE QUESTIONS

PKI is required by law to give you this Notice and to follow the terms of the Notice that are currently in effect. If you have any questions about this Notice, or have further questions about how PKI may use and disclose your medical information, please contact PKI’s Privacy Administrator.

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