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.

Our Commitment to Your Privacy

Mi Clínica Hispana, LLC (“the Practice,” “we,” “us,” or “our”) is committed to protecting the privacy of your health information. We are required by law (the Health Insurance Portability and Accountability Act of 1996, or “HIPAA,” and its implementing regulations) to maintain the privacy of your protected health information (“PHI”), to provide you with this Notice describing our legal duties and privacy practices, and to notify you in the event of a breach of your unsecured PHI.

How We May Use and Disclose Your Health Information

We may use and disclose your health information for the following purposes without your written authorization:

• Treatment. We may use and share your health information with other professionals who are treating you, and to coordinate or manage your care, such as referrals to specialists.

• Payment. We may use and disclose your health information to bill and collect payment for the treatment and services you receive, including verifying insurance coverage and processing claims.

• Health Care Operations. We may use and disclose your health information for our healthcare operations, such as quality assessment, staff training, licensing, and other administrative activities.

• As Required by Law. We will disclose your health information when required to do so by federal, state, or local law, including reporting to public health authorities.

• Public Health Activities. We may disclose health information to public health authorities for purposes such as preventing disease, reporting child abuse or neglect, and reporting reactions to medications.

• Health Oversight Activities. We may disclose health information to health oversight agencies for activities authorized by law, such as audits and investigations.

• Judicial and Administrative Proceedings. We may disclose health information in response to a court or administrative order, subpoena, discovery request, or other lawful process.

• Law Enforcement. We may disclose health information to law enforcement officials for purposes such as identifying a suspect, fugitive, witness, or missing person, in compliance with applicable law.

• To Avert a Serious Threat to Health or Safety. We may disclose health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public.

• Workers' Compensation. We may disclose health information as authorized by, and to the extent necessary to comply with, workers' compensation laws.

• Research. We may use or disclose health information for research purposes in limited circumstances, subject to a special approval process.

• Organ and Tissue Donation. If you are an organ donor, we may release health information to organizations that handle organ procurement or transplantation.

• Military, Veterans, and National Security. We may disclose health information of Armed Forces personnel for activities deemed necessary by appropriate military command authorities, or to authorized federal officials for national security and intelligence activities.

Uses and Disclosures Requiring Your Written Authorization

Other uses and disclosures of your health information not described in this Notice will be made only with your written authorization. This includes, for example, most uses and disclosures of psychotherapy notes, uses and disclosures for marketing purposes, and disclosures that constitute a sale of PHI. You may revoke an authorization at any time, in writing, except to the extent we have already acted in reliance on it.

Your Rights Regarding Your Health Information

• Right to Access and Copy. You have the right to inspect and obtain a copy of your health information, with limited exceptions. We may charge a reasonable, cost-based fee for copies.

• Right to Amend. You have the right to request that we amend your health information if you believe it is incorrect or incomplete. We may deny your request under certain circumstances.

• Right to an Accounting of Disclosures. You have the right to receive a list of certain disclosures we have made of your health information for purposes other than treatment, payment, and health care operations.

• Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of your health information. We are not required to agree to all requests, but must agree to a restriction on disclosure to a health plan if the disclosure is for payment or operations and relates to a service you paid for in full out of pocket.

• Right to Request Confidential Communications. You have the right to request that we communicate with you about your health information in a certain way or at a certain location (for example, by mail to a different address).

• Right to a Paper Copy. You have the right to obtain a paper copy of this Notice upon request, even if you have agreed to receive it electronically.

• Right to Notification of a Breach. You have the right to be notified in the event we (or a business associate) discover a breach of your unsecured health information.

• Right to File a Complaint. You have the right to file a complaint with us or with the U.S. Department of Health and Human Services if you believe your privacy rights have been violated. We will not retaliate against you for filing a complaint.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this Notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us, in writing, that we can. If you tell us we can, you may change your mind at any time by notifying us in writing.

Changes to This Notice

We reserve the right to change this Notice at any time. The revised Notice will apply to health information we already have about you as well as information we receive in the future. A copy of the current Notice will be available at our office and, if applicable, on our website.

Contact Information / Complaints

If you have questions about this Notice or wish to exercise any of the rights described above, please contact our Privacy Officer:

• Alaina Hernandez, NP – Privacy Officer

• Mi Clínica Hispana, LLC

• 3505 Summerhill Rd, Ste 5, Texarkana, TX 75503

• Phone: 903-710-1400

• Email: admin@miclinicahispana.net

You may 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/privacy/hipaa/complaints/.