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