Notice of Privacy Practices

THIS NOTICE IS PROVIDED IN ACCORDANCE WITH THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (“HIPAA”) AND DESCRIBES HOW MARYLAND WEIGHT CARE, LLC (“PROVIDER”) MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (“PHI”), AND WHAT RIGHTS YOU HAVE TO ACCESS SUCH PHI MAINTAINED BY PROVIDER. PLEASE REVIEW THIS NOTICE CAREFULLY AND IN FULL.

Provider is committed to protecting your privacy and is required by law to maintain the privacy of your PHI. As part of your treatment by Provider, Provider will ask for certain health and medical information that will be made a part of your medical record, which may be used for a variety of purposes, as further set forth herein. As used herein, PHI means your medical record and includes any identifiable information that we obtain from you or others that relate to your physical or mental health, the health care you have received from Provider or from any other medical practitioner in the past, or payment records with respect to such health care and treatment. Provider shall maintain and protect the privacy of your PHI and medical record at all times in accordance with the policies set forth herein, provided that, Provider reserves the right to make updates to its policies at any time, provided that Provider shall promptly notify you of any such update to this policy, in accordance with HIPAA and all applicable law. You may request a copy of this notice for your records. A copy of this notice is also available on our website at www.mdweightcare.com.

PERMITTED USES AND DISCLOSURES

Provider, and any employees thereof, shall only use or disclose your PHI or medical record in direct connection with the provision of medical treatment or services in the ordinary course of Provider’s business function as a medical practice. Provider must have your written authorization for any use or disclosure of your PHI for purposes other than the following:

• Treatment: Provider may use and disclose your PHI to provide health care and related services to you. For example, we may use or disclose your PHI to a physician or other health care provider in order to treat you or to assist others in your treatment. Other examples include uses and disclosures for laboratory tests, prescriptions, and referrals to other health care providers for additional health care services.

• Payment: Provider may use and disclose your PHI in order to bill and collect payment for the services and items you may receive and to determine your eligibility to participate in our services. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for your treatment. We also may use and disclose your PHI to obtain payment from you or from third parties that may be responsible for such costs, such as family members.

• Health Care Operations: We may use and disclose your PHI in connection with our health care operations, including but not limited to, our administrative, financial, legal, and quality improvement activities, training of staff, cost-management, business planning, and the preparation of de-identified information and limited data sets for limited research purposes.

• Business Associates: We may share your PHI with third-party “business associates” that provide various services for us, such as billing, transcription, software maintenance, accreditation and legal services, provided that, in any such instance, we will have executed a Business Associate Agreement with such vendor or business associate which obligates such vendor or business associate to maintain the confidentiality of your PHI in accordance with applicable law and the standards set forth herein.

• Health Related Services: We may use and disclose your PHI to tell you of or recommend treatment alternatives and other health related benefits and services that might be of interest to you.

• Incapacity: If you are not present or are incapacitated, or in an emergency situation, we will disclose your PHI based upon our professional judgment that disclosure is in your best interest. We will also use our professional judgment and experience with common practice to allow a person to pick up prescriptions, medical supplies, x-rays or similar types of medical information. We will not, however, disclose any information in a way that conflicts with a previously agreed upon preference or restriction.

• As Required or Permitted by Law: Provider may use and disclose your PHI when we are required or permitted to do so by applicable federal, state and/or local law. Such uses or disclosures will be made in compliance with the applicable law and, to the extent required by law you will be notified of any such uses and disclosures. Such uses and disclosures required by law may include, but are not necessarily limited to, those required by federal, state or local law, statute or ordinance, pursuant to a lawful court or administrative order, subpoena, discovery request or under other legal proceeding in a venue of competent jurisdiction, and may include such additional circumstances as set forth below:

o Public Health.

• to report matters related to the quality, safety, or effectiveness of a product or service regulated by the Food and Drug Administration (FDA)
• to prevent or control disease, injury or disability
• to report disease or injury
• to report child abuse or neglect
• to report reactions to medications in a de-identified manner
• to notify people of recalls or replacements of products they may be using
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
• to notify the appropriate government authority if we believe a person has been the victim of abuse neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

o Health Oversight Activities. We may disclose your PHI to a health oversight agency as required by law, for example, to comply with audits, investigations, inspections, licensure or disciplinary actions. These activities are needed to monitor the health care system, government programs, and compliance with civil rights laws.

o Serious Threats to Health or Safety. We may use and disclose your PHI when we believe it is necessary to reduce or prevent a serious threat to your health or safety or the health or safety of another person or the public. Any such disclosures would be made to persons or organizations able to help prevent or lessen the threat.

o Organ and Tissue Donation. We may release PHI to authorized organizations relating to organ, eye or tissue donations or transplants.

o Military and Veterans. If you are a member of the armed forces of the United States or another country (including veterans), we may release your PHI as required by military command authorities.

o Workers’ Compensation. We may disclose your PHI to comply with workers’ compensation laws or similar programs that provide benefits for work-related injuries or illness.

o Coroners, Medical Examiners and Funeral Directors. We may disclose PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors so they can carry out their duties.

o In Legal Custody. If you are an inmate of a correctional institution or under custody of a law enforcement official, we may disclose health information about you to the correctional institution or law enforcement official.

AUTHORIZATION

Provider shall not use or disclose your PHI except as permitted hereby. For any purposes other than the ones described above, we will only use or disclose your PHI when you give us written Authorization specifying the party to whom such PHI may be disclosed and the limited purpose or use for which such disclosure is being made. You may give us written Authorization to use your PHI or to disclose it to anyone for any purpose. If you give us an Authorization, you may revoke it in writing at any time, but your revocation will not be effective with respect to any actions taken by Provider in reliance on the Authorization prior to Provider’s receipt of written revocation thereof.

RESTRICTIONS

Federal and/or applicable Maryland laws may otherwise limit the ways that we may use or disclose your PHI or they may require different privacy protections for certain types of information that are considered highly confidential. Such highly confidential information may include health information pertaining to drug or alcohol abuse treatment; mental health care; HIV/AIDS; developmental disabilities; or genetic testing. We will not use or disclose your PHI in a way that is prohibited by any applicable law.

YOUR RIGHTS

With respect to your PHI, and Provider’s use and disclosure thereof, you have the following rights:

• Confidential Communications: You have the right to request that we communicate with you about your health care and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than at work, or by some alternative means of contact. Reasonable requests will be accommodated. You do not need to give a reason for your request.

• Requesting Restrictions: You have the right to request certain restrictions regarding our use or disclosure of your PHI. This means that you may ask us not to use or disclose part of your PHI for certain treatment, payment or health care operations purposes. You may also request that we not disclose all or part of your PHI to individuals (such as family members and friends) involved in your health care or the payment for your care. Except as otherwise required by law or under emergency medical situations as determined in Provider’s professional judgement, we will adhere to the specifications made in any such request. If you pay out of pocket for a service or health care item, you may also request that we do not disclose information about your treatment to your health insurer.

• Inspection and Copies: You have the right to look at and obtain a copy of the PHI we maintain that may be used to make decisions about you. Usually, this includes patient medical records and billing records but not psychotherapy notes or legal and other materials as provided by law. In some limited circumstances, we may deny your request to see or copy your PHI and, depending on the circumstances, you may have the right to request a review of our denial. We may charge a fee for the costs of copying, mailing, and supplies associated with your request. We will tell you the amount of the fee in advance.

• Amendment: You may ask us to amend your PHI if you believe it is incorrect or incomplete. To request an amendment, your request must be made in writing.You must clearly describe the change(s) you are requesting and you must explain why the information should be amended. We may deny your request if we believe that the information that would be amended is already accurate and complete or if other special circumstances apply. If we deny your request, we will provide you with a written explanation of the denial and your right to submit a statement disagreeing with the denial. If we approve the request for amendment, we will inform you and change the health information, and we will tell others that need to know of the change.

• Accounting of Disclosures: You have the right to request a list of the disclosures we have made of your PHI. The list does not have to include disclosures made to you or with your Authorization, for treatment, payment and health care operations purposes, or in connection with certain other activities. In order to obtain an accounting of disclosures, you must submit your request in writing at the address provided below. All requests for an accounting must state a time period, which may not be longer than six (6) years from the date of disclosure. If you request an accounting more than once in a 12 month period we may charge a reasonable cost-based fee of which you will be notified in advance.

ADDITIONAL INFORMATION

If you have further questions about these privacy policies, or your rights pertaining thereto, you may contact Dr. Christina Parisi at any time, at the following address:

Maryland Weight Care, LLC

attn: Christina Parisi, M.D.

8850 Stanford Blvd Suite 2400

Columbia, MD 21045

DrParisi@mdweightcare.com

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

1. Patient acknowledges and agrees that Patient has been provided with a copy of Provider’s Notice of Privacy Practices, which describes how Provider may use and disclose Patient’s Protected Health Information (“PHI”) in accordance with applicable law.

2. Patient hereby acknowledges and agrees to the effectiveness of any signature delivered by Patient hereunder by email (in .pdf format), recognized e-signature software or application, or other means of electronic transmission having a verifiable time and date stamp mechanism.