AFFORDABLE KETAMINE CLINICS, LLC | PRIVACY POLICY©

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.

Affordable Ketamine Clinics, LLC (“Affordable Ketamine Clinic”), and its representatives, are committed

to protecting the confidentiality of our patients’ medical information. This Notice describes how Affordable

Ketamine Clinic may use your medical information within Affordable Ketamine Clinic, and how we may

disclose it to others outside of Affordable Ketamine Clinic. 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: Affordable Ketamine Clinic may use your medical information to provide you with medical

services and supplies. Affordable Ketamine Clinic 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 Affordable Ketamine

Clinic medical record to assist in your follow-up care. Affordable Ketamine Clinic 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: Affordable Ketamine Clinic 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. Please provide to Affordable Ketamine Clinic a signed list of family members or

others to whom we may disclose your medical information to. You may modify this list at any time in

writing.

Payment: Affordable Ketamine Clinic 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 Affordable Ketamine Clinic for

your treatment.

Healthcare Operations: Affordable Ketamine Clinic may use and disclose your medical information to its

staff within the Affordable Ketamine Clinic if it is necessary to improve the quality of care provided to

patients or to run Affordable Ketamine Clinic. 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 – Affordable Ketamine Clinic staff members may look at your medical records

to evaluate whether Affordable Ketamine Clinic personnel, your doctors, or other health care professionals

did a good job, or accounting auditors may look at your records to evaluate financial practices and income.

Research: Affordable Ketamine Clinic may use or disclose your medical information for research projects,

such as studying the effectiveness of a treatment you received, but your name and contact information will

be deleted (redacted) from such disclosures. You will be contacted for authorization if research projects are

such that they must go through additional processes that protect the confidentiality of your medical

information.

Required by Law: Federal, state or local laws may require Affordable Ketamine Clinic to disclose patients’

medical information.

Public Health: Affordable Ketamine Clinic may report certain medical information for public health

purposes. Affordable Ketamine Clinic 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: Affordable Ketamine Clinic 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 Affordable Ketamine Clinic.

We may disclose your medical information to law enforcement officials and others to prevent a serious

threat to health or safety of the community or an individual.

Health Oversight Activities: Affordable Ketamine Clinic may disclose medical information to a

government agency that oversees Affordable Ketamine Clinic or its personnel, and requires medical

information to monitor Affordable Ketamine Clinic’s compliance with state and federal laws.

Military, Veterans, National Security and Other Government Purposes: If you are a member of the armed

forces, Affordable Ketamine Clinic may release your medical information as required by military command

authorities or to the Department of Veterans Affairs. Affordable Ketamine Clinic may also disclose medical information to federal officials for intelligence and national security purposes or for presidential protective

services.

Judicial and Administrative Proceedings: Affordable Ketamine Clinic may disclose medical information in

any judicial or administrative proceeding if ordered to do so by a court, or if Affordable Ketamine Clinic

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. Affordable Ketamine Clinic is required to obtain 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 Affordable Ketamine Clinic wishes to use or disclose your medical

information for a purpose that is not discussed in this Notice, Affordable Ketamine Clinic will seek your

permission. Permission granted to Affordable Ketamine Clinic may be rescinded at any time, unless

Affordable Ketamine Clinic has already acted on your permission to use or disclose the information. To

revoke your permission, please notify Affordable Ketamine Clinic in writing at: affordableketamine.com or

375 North Main Street, Suite 202, Kaysville, Utah 84037.

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 Affordable Ketamine Clinic 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 Affordable Ketamine Clinic’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 the disclosures Affordable Ketamine Clinic makes of your medical information. To receive a list,

please contact Affordable Ketamine Clinic. 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 Affordable Ketamine Clinic Will Use or Disclose Your Medical

Information for Treatment, Payment or Health Care Operations: You have the right to ask Affordable

Ketamine Clinic not to make use or disclosure of your medical information to treat you, to seek payment for

care, or to operate Affordable Ketamine Clinic. 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, Affordable Ketamine Clinic is not required to agree to your request. If

we do agree, we will comply with that agreement. To request a restriction, please contact Affordable

Ketamine Clinic and describe your request in detail.

Right to Request Confidential Communication: You have the right to ask Affordable Ketamine Clinic 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. Your confidential communications request must be in

writing. You have the right ask to speak with your health care providers in private, outside the presence of

anyone other than Affordable Ketamine Clinic staff members.

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 Affordable Ketamine Clinic facility.

CHANGES TO THIS NOTICE:

From time to time, Affordable Ketamine Clinic may change its practices concerning how it uses or

discloses patient medical information, or how Affordable Ketamine Clinic will implement patient rights

concerning their information. Affordable Ketamine Clinic 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 Affordable

Ketamine Clinic’s current Notice of Privacy Practices may be obtained by contacting Affordable Ketamine

Clinic or by visiting our website.

HEALTH CARE PROVIDERS COVERED BY THIS NOTICE:

This Notice of Privacy Practices applies to Affordable Ketamine Clinic and its representatives and

personnel. Affordable Ketamine Clinic 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 Affordable Ketamine Clinic. 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 Affordable

Ketamine Clinic uses or discloses your medical information. If you have a concern, please contact

Affordable Ketamine Clinic at affordableketamine.com or call 801.450.7147.

If Affordable Ketamine Clinic 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:

Affordable Ketamine Clinic 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

Affordable Ketamine Clinic may use and disclose your medical information, please contact Affordable

Ketamine Clinic’s Privacy Officer at affordableketamine.com or call 801.450.7147.

ACKNOWLEDGEMENT

By visiting and engaging on this site I agree to the  Affordable Ketamine Clinic’s Privacy Policy.

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