Patient Registration

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. In accordance with the Health Insurance Portability and Accountability Act we are required by law to provide you with this notice that explains out privacy practices with regard to your medical information and how we may use and disclose your protected health information for treatment, payment, and for health care operations, as well as for other purposes that are permitted or required by law. You have certain rights regarding the privacy of your protected health information and we also describe them in this notice. Treatment: We will use and disclosed your protected health information to provide, coordinate, or manage your health care and any related services. We will also disclose your health information to other physicians who may be treating you. Additionally, we may from time to time disclose your health information to another physician who we have requested to be involved in you care. For example – we would disclose your health information to a specialist whom we have referred you for a diagnosis to help in your treatment. Payment: We will use and disclose your protected health information to obtain payment for the health care services we provide you. For example – we may include information with a bill to a third-party payer that identifies you, your diagnosis, procedures performed, and supplies used in rendering the service. Health Care Operations: We will use and disclose your protected health information to support the business activities of our practice. For Example-we may use medical information about you to review and evaluate our treatment and services or to evaluate our staff’s performance while caring for you. In addition, we may disclose your health information to third party business associates who perform billing, consulting, or transcription services for our practices. Other Ways We May Use and Disclose Your Protected Health Information: - Appointment Reminders: We will use and disclose your protected health information to contact you as a reminder about scheduled appointments or treatment. - Treatment Alternatives: We will use and disclose your protected health information to tell you about or to recommend possible alternative treatments or options that may be of interest to you. - Others Involved in Your Care: We will use and disclose your protected health information to a family member, a relative, a close friend, or any other person you identify that is involved in your medical care or payment for care. - Researched: We will use and disclose your protected health information to researchers provided the research has been approved by an institutional review board that has reviewed the research proposal and establish protocols to ensure the privacy of your health information. - As Required by Law: We will use and disclose your protected health information hen required to by federal, state, or local law. You will be notified of any such disclosures. - To Avert a Serious Threat to Public Health or Safety: We will use and disclose your protected health information to a public health authority that is permitted to collect or receive the information for the purpose of controlling disease, injury, or disability. If directed by that health authority, we will also disclose your health information to a foreign government agency that is collaborating with the public health authority.

Although your health record is the physical property of the health care practitioner or facility that compiled it, the information belongs to you. You have the right to: A Paper Copy of This Notice: You have the right to receive a paper copy of this notice upon request. You may obtain a copy by asking our receptionist at your next visit or by calling and asking us to mail you a copy. Inspect and Copy: You have the right to inspect and copy the protected health information that we maintain about you in our designated record set for as long as we maintain that information. This designated record set includes your medical billing records, as well as any other records we use for making decisions about you. Any psychotherapy notes that may have been included in records we received about you are not available for your inspection or copying by law. We may charge you a fee for the costs of copying, mailing, or other supplies used in fulfilling your request. If you wish to inspect or copy your medical information, you must submit your request in writing to Attn: Privacy Officer/Vital Urgent Care 2507 Eastbluff Drive, Newport Beach, CA 92660. You may mail in your request, or bring it to our office. We will have 30 days to respond to your request for information that we maintain at our practice site. If the information is stored off-site, we are allowed up to 60 days to respond but must inform you of this delay. Request Amendment: You have the right to request that we amend your medical information if you feel that it is incomplete or inaccurate. You must make this request in writing to our practice manager, stating exactly what information is incomplete or inaccurate and your reasoning that supports you request. We are permitted to deny your request if it is not in writing or does not include a reason to support the request. We may also deny your request if: - The information was not created by us, or the person who created it is no longer available to make the amendment; - The information is not part of the record which you are permitted to inspect and copy; - The information is not part of the designated record set kept by this practice; or if it is the opinion of the health care provider that the information is accurate and complete. Request Restrictions: You have the right to request a restriction or limitation of how we use or disclose your medical information for treatment, payment, or health care operations. For example – you could request that we not disclose information about a prior treatment to a family member or friend who may be involved in your care or payment for care. Your request must be made in writing to our practice manager. We are not required to agree to your request if we feel it is in your best interest to use or disclose that information. However, if we do agree, we will comply with your request unless that information is needed for emergency treatment. An Accounting of Disclosures: You have the right to request a list of the disclosures of your health information we have made outside of our practice that was not for treatment, payment, or health care operations. Your request must be made in writing and must state the time period for the requested information. You may not request information for any dates prior to April 14, 2003 (the compliance date for the federal regulation) nor for a period of time greater than six years (our legal obligation to retain information). Your first request for a list of disclosures within a 12-month period will be free. If you request an additional list within 12-months of the first request, we may charge you a fee for the costs of providing the subsequent list. We will notify you of such costs and afford you the opportunity to withdraw your request before any costs are incurred. Request Confidential Communications: You have the right to request how we communicate with you to preserve your privacy. For example – you may request that we call you only at your work number, or by mail at a special address or postal box. Your request must be made in writing and must specify how or where we are to contact you. We will accommodate all reasonable requests. File a Complaint: If you believe we have violated your medical information privacy rights, you have the right to file a complaint with our practice manager or directly to the Secretary of Health and Human Services. To file a complaint with our manager, you must make it in writing within 180 days of the suspected violation. Provide as much detail as you can about the suspected violation and send it to Attn: Privacy Officer 2507 Eastbluff Drive Newport Beach, CA 92660. You should know that there would be no retaliation for your filing a complaint.

Uses or disclosures of your health information not covered by this notice or the laws that apply to us may only be made with your written authorization. You may revoke such authorization in writing at any time and we will no longer disclose health information about you for the reasons stated in your written authorization. Disclosures made in reliance on the authorization prior to the revocation are not affected by the revocation. For More Information: Please call us at (949) 200-1655 for any questions or additional information.

I acknowledge that in order to protect my privacy, I need to choose a private location to place my telemedicine call. I understand that in order to provide the best call environment, I should reduce background light from windows or light emanating from behind me. I should not be driving or operating a moving vehicle while having the telemedicine session. I understand that providers can not speak to a patient while driving due to liability reasons. I understand that my camera should be placed on a secure, stable platform to avoid wobbling and shaking during the telemedicine session. To the extent possible, my camera should be placed at the same elevation as my eyes with my face clearly visible to the other person. I understand that I will be informed of the presence of any third party, including those that may be present to assist with the audio or video equipment, and that I have the right to: (1) omit specific details of medical history or physical examination that are sensitive to me during such third party presence, (2) ask non-medical personnel to leave the telemedicine examination room, and/or (3) terminate the consultation at any time by notifying the Practitioner or disconnecting from the telemedicine portal. I understand the potential risks of receiving the Services via telemedicine include: delays in medical evaluation due to technological equipment failure, a lack of access to all relevant information, or a security breach allowing unauthorized access to my confidential medical information. I understand that my Practitioner or I may terminate the telemedicine visit at any time, including if the Practitioner or I feel that an in-person visit is necessary for any reason. I have had the Services and alternatives to telemedicine for my Services explained to me and I choose to and continue with a telemedicine visit. I understand that any complaint may be filed with the Secretary of the Department of Health and Human Services. I have read and understood the written information provided above. I agree that the information provided above adequately explains the Services, along with the risks and benefits to me of said Services. I have had the opportunity to ask questions about this information – if I had any questions, all of my questions have been answered in full. By electronically signing this form, I acknowledge and agree to all of the above, and certify that I have no questions and/or have had my questions answered in full. By electronically signing this informed consent, I am agreeing to conduct transactions electronically, and intend for my electronic signature to be a binding electronic signature on myself and those I am authorized to represent. Further, I understand and acknowledge that I am digitally receiving a copy of this Agreement concurrently upon execution to print and/or retain a copy of this Agreement, and may also request a paper copy from Sick Clinic.