NOTICE OF PRIVACY PRACTICES

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

Effective Date August 1st, 2022

It is important to read and understand this Notice of Privacy Practices (Notice) before signing the Consent and Acknowledgement Form. If you have questions about this Notice or would like further information concerning your privacy rights, please contact:

Nourish Total Health, LLC

Jessica VanGessel, Privacy Officer

8650 Byron Center Ave SW Ste 12

Byron Center, Michigan 49315

Tel: 616-389-0913

Fax: 940-340-3615

A. PURPOSE OF THIS NOTICE.

Nourish Total Health, LLC is committed to preserving the privacy of your protected health information (PHI). For purposes of this Notice, “Nourish Total Health” “we” and “us” will refer to all services, service areas, and staff of Nourish Total Health. When we use the acronym “PHI” we mean any information that you have given us about you and your health, either in written, electronic or spoken words, as well as information that we have received about you (including health information provided to Nourish Total Health by those outside of Nourish Total Health). Your PHI is information about you created and received by us, including demographic information, that may reasonably identify you and that relates to your past, present, or future physical or mental health or condition, or payment for the provision of your health care.

The Notice tells you how we can and cannot use and disclose PHI that you have given to us or that we have learned about you when you were a patient in our system. This Notice also tells you about your rights and our legal duties concerning your PHI.

Nourish Total Health is required to abide by this Notice. This Notice applies to the practices of:

-All Nourish Total Health employees, contractors, volunteers, students and service providers, including clinicians, who have access to your PHI.

-Any health care professional authorized to enter information into your Nourish Total Health health record.

B. USES AND DISCLOSURES OF PHI FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

For Treatment. We may use your PHI to provide you with health care services. We may disclose your health information to physicians, nurse practitioners, nurses, technicians and other personnel involved in your health care and for purposes of coordinating or managing your health care and are related services. For example, if you are being treated for depression, we may disclose your health information to your treating physician to coordinate your care. We may also use or disclose your PHI in an emergency situation.

For Payment. We may use and disclose your PHI so that we may bill and collect payment for the services you receive. For example, we may need to give your health plan information about the services your received in order to be reimbursed, or we may contact your health plan to confirm your coverage or request prior authorization for a services.

For Health Care Operations. We may use and disclose your PHI as necessary for operations of Nourish Total Health, such as quality assurance and improvement activities, reviewing the competence and qualifications of health care professionals, medical review, legal services and auditing functions and general administrative activities of Nourish Total Health.

C. OTHER PERMITTED USES AND DISCLOSURES OF PHI

Business Associates. There may be some service provided by your business associates, such as a billing service, transcription, company or legal or accounting consultants. We may disclose your PHI to our business associate so that they can perform the job we have them to do. To protect your PHI, we require our business associates to enter into a written contract that requires them to appropriately safeguard your information.

Appointment Reminders. We may use and disclose PHI to contact you as a reminder that you have an appointment at Nourish Total Health.

Treatment Alternatives and Other Health-Related Benefits and Services. We may use and disclose PHI to tell you about or recommend possible treatment options or alternatives to tell you about health related benefits, services, or medical education classes that may be of interest to you.

Individuals Involved in Your Care or Payment of Your Care. Unless you object, we may provide disclose your PHI to individuals, such as family and friends, who are involved in your care if the information relates to notifying the identified person of your location, general condition, or payment related to your health care. In addition, we may disclose your PHI to a public or private entity authorized by law to assist in disaster relief. Effort. If you are unable to agree or object to such disclosure, we may disclose such information if we determine that it is in your best interest based on our professional judgment or if we reasonably infer that you would not object. For example, we may assume you agree to our disclosure of your information to your spouse if your spouse comes with you into the room during a consultation or visit.

Victims of Abuse, Neglect or Domestic Violence. To a government authority authorized by law to receive reports of abuse, neglect or domestic violence or when we reasonably believe you are the victim of abuse, neglect or domestic violence and other criteria are met.

Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, accreditation, licensure and disciplinary actions. To a health oversight agency for audits, investigations, inspections, licensing purposes, or as necessary for certain government agencies and peer review organizations performing utilization and quality control and oversight.

Judicial or Administrative Proceedings, Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your PHI to in response to your authorization or a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request, or other lawful process if such disclosure is permitted by law.

Law Enforcement. We may disclose your PHI for certain law enforcement purposes if permitted or required by law. For example, to report gunshot wounds; to report emergencies or suspicious deaths; to comply with a court order, warrant, or similar legal process; or to answer certain request for information concerning crimes.

To Avert Serious Threat to Health or Safety. We may use and disclose your PHI when necessary to prevent or lessen a serious threat to your health and safety or safety of the public or another person. Any disclosure would be to someone able to help prevent the threat.

Research. We can use or share your PHI for health research through an approved special Privacy Board or Institutional Review Board, or if you provide authorization.

Medical Examiner, Funeral Directors, Organ Procurement Organizations. We can share your PHI with a coroner, medical examiner, organ procurement organization, or funeral director.

Public Health and Safety. We may disclose your PHI to a public health authority that is authorized by law to collect or receive such information, for the purpose of preventing or controlling disease, injury, or disability; reporting births, deaths, or other vital statistics; reporting child or elder abuse or neglect; notifying individuals of recalls of products that may be using; or notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition.

Workers’ Compensation. We may use or disclose your PHI as permitted by laws relating to workers’ compensation or related programs.

Electronic Transmission. We may use or disclose your PHI by email or text, subject to your approval, related to services provided by Nourish Total Health.

Required by Law. As required by federal, state, or local law.

D. YOUR RIGHTS REGARDING YOUR PHI.

You have certain rights regarding your health information, which we list below. In each of these cases, if you want to exercise your rights, you must do so in writing by completing a form that you can obtain from Nourish Total Health. In some cases, we may charge you for the costs of providing materials to you.

Right to Inspect and Copy Your PHI. With some exceptions, you have the right to access, inspect and get a copy of your PHI that we use to make decisions about your care. You must submit your request in writing to Nourish Total Health. For the portion of your health record maintained in our electronic health record, you may request we provide that information to or for you in an electronic format. If you make such a request, we are required to provide that information for you electronically (unless we deny your request for other reasons). We may deny your request in whole or in part under certain limited circumstances. If we deny your request, we will provide you with a written explanation of the reason or the denial. You may have the right to have this denial reviewed by an independent health care professional designated by us to act as a review official. This individual will not have participated in the original decision to deny our requests. You may also have the right to request a review of our denial or access through a court of law. All requirements, court costs, and attorneys’ fees associated with a review of denial by a court are your responsibility.

Right to Amend. You have the right to request to amend your PHI maintained by or for Nourish Total Health or used by Nourish Total Health to make decisions about you provided the information is maintained by or for Nourish Total Health. Your request must be made in writing and must state the reason for the request. We are not obligated to agree to your request to amend your health information. We may deny your request for an amendment if the request is not properly submitted, or if it asks us to amend information that (a) we did not create (unless the source of the information is no longer available to make the amendment); (b) is not part of the health information that we keep; (c) is of a type that you would not be permitted to inspect and copy; or (d) is already accurate and complete. If we deny your request for an amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy.

Right to an Accounting of Disclosures. You have the right to request a list and description of certain disclosures of your PHI by Nourish Total Health. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.

Right to Request Restrictions. You have the right to request a restriction or limitation on how your PHI is used or disclosed by Nourish Total Health. Your request must be in writing stating the time period of your request and the specific restriction requested. We are not required to agree to you request unless the request is to restrict disclosure of health information to a health plan for purposes of carrying out payment or health care operations, and the health information pertains to health care services that you paid for out of pocket. In that case, we will honor your request for a restriction.

Right to Receive Confidential Communications. You have the right to request a reasonable accommodation regarding how you receive communications of PHI. You have the right to request an alternative means of communication or an alternative location where you would like to receive communications. You must submit your request for confidential communications in writing.

Right to Copy of this Notice. You have the right to request a paper copy of this Notice even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time or obtain a copy of this Notice on our web address.

File a Complaint If You Feel Your Rights Are Violated. You can complain if you feel we have violated your rights by contacting us using the information on page 1. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr You will not be penalized for filing a complaint and we will make every reasonable effort to resolve your complaint with you.

CHANGES TO THE TERMS OF THIS NOTICE. We can change the terms of this Notice, and the changes will apply to all information we have about you. The new notice will be made available upon request, in our office and on our website at www.nourishtotalhealth.com.