Your SYNC Life health story

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.

I. Our Commitment to Your Privacy

At SYNC Life, we are committed to maintaining the privacy and confidentiality of your Protected Health Information (PHI). PHI includes individually identifiable health information created, received, or maintained by us relating to your physical or mental health, healthcare services provided to you, or payment for healthcare services.

We are required by law, including the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and 42 CFR Part 2 (where applicable), to:

• Maintain the privacy and security of your PHI and Substance Use Disorder (SUD) records.
• Provide you with this Notice of Privacy Practices detailing our legal duties and privacy practices.
• Notify you promptly following a breach of your unsecured PHI.
• Abide by the terms of this Notice currently in effect.

II. How We May Use and Disclose Your Health Information

We may use and disclose your PHI for treatment, payment, and healthcare operations without your explicit written authorization under standard conditions, subject to specific restrictions for sensitive information described below.

1. Treatment

We use and share your health information to provide, coordinate, or manage your care. For example, our functional medical practitioners may share information regarding cellular micronutrient testing, hormone levels, or wellness plans with nurses, laboratory technicians, or consulting specialists involved in your care.

2. Payment

We may use and disclose your PHI to bill and collect payment from you, your health insurance plan, or third parties for the services you receive. For example, we may send a bill to your insurance company or process payment for IV hydration therapy or primary care visits.

3. Healthcare Operations

We may use and share your PHI to run our practice, improve quality of care, train staff, and perform administrative functions. For example, we may use clinical data to evaluate the effectiveness of our protocols or conduct compliance reviews.

4. Appointment Reminders and Service Communications

We may contact you to provide appointment reminders, follow-up messages regarding lab results, or information about treatment alternatives and health-related benefits/services that may interest you.

III. Special Privacy Protections for Sensitive Data

1. Substance Use Disorder (SUD) Records (42 CFR Part 2)

If SYNC Life receives, creates, or maintains records originating from a Substance Use Disorder (SUD) treatment program governed by 42 CFR Part 2, enhanced federal privacy rules apply:

• Single Consent for Future Uses/Disclosures: Once you sign a written consent permitting us to use or disclose your Part 2 SUD records for treatment, payment, or healthcare operations, we may make subsequent uses and disclosures of those records (including redisclosures) as permitted by HIPAA, until you revoke your consent in writing.
• Restriction on Legal Proceedings: SUD records or information derived from them cannot be used or disclosed in criminal, civil, administrative, or legislative proceedings against you without your specific written consent or a court order meeting federal 42 CFR Part 2 requirements.
• Redisclosure Notice: Any redisclosure of Part 2 records to third parties will be accompanied by the required federal notice prohibiting further disclosure without express authorization.

IV. Disclosures Requiring Written Authorization

For purposes not covered by standard treatment, payment, or healthcare operations, or where required by state/federal laws, we will obtain your explicit written authorization before using or disclosing your PHI. Specific examples include:

• Psychotherapy Notes: Most uses and disclosures of psychotherapy notes require your written authorization.
• Marketing: We will not use or disclose your PHI for marketing purposes or receive financial remuneration for selling your PHI without your signed authorization.
• Other Uses: Any other use or disclosure not described in this Notice will be made only with your written authorization, which you may revoke in writing at any time.

V. Uses and Disclosures Permitted or Required by Law

In certain situations, federal or state law permits or requires us to disclose your PHI without your authorization or opportunity to object:

• Public Health and Safety
• Health Oversight Activities
• Judicial and Administrative Proceedings
• Law Enforcement
• Organ and Tissue Donation / Coroners
• Threat to Health or Safety
• Worker's Compensation

VI. Your Individual Rights Regarding Your PHI

1. Right to Inspect and Copy. You have the right to inspect and obtain an electronic or paper copy of your medical and billing records. We will provide a copy or summary within 30 days of your written request. We may charge a reasonable, cost-based fee.
2. Right to Request Restrictions. You have the right to ask us to restrict or limit how we use or disclose your PHI for treatment, payment, or healthcare operations. While we are not required to agree to every request, we must agree if you request that we not send PHI to your health plan for payment or healthcare operations purposes, and the PHI pertains solely to an item or service for which you (or someone on your behalf) paid SYNC Life in full out-of-pocket.
3. Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a specific way or at a specific location. We will accommodate all reasonable requests.
4. Right to Amend Your Records. If you feel that the health information we have about you is incorrect or incomplete, you may request an amendment in writing. You must state the reason for the request. We may deny your request under certain conditions, but we will inform you of the reason in writing within 60 days.
5. Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures of your PHI made by SYNC Life for up to six years prior to the date of your request, subject to the exclusions described in this Notice.
6. Right to Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice at any time, even if you previously agreed to receive it electronically.

VII. Changes to This Notice of Privacy Practices

SYNC Life reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI that we maintain, including PHI created or received prior to issuing the revised Notice. When changes are made, we will promptly post the revised Notice in our facility, publish it on our website, and make copies available upon request.

VIII. Complaints and Contact Information

If you believe your privacy rights have been violated, or if you have questions about this Notice, you may file a complaint with SYNC Life or with the Secretary of the U.S. Department of Health and Human Services (HHS).

SYNC Life Compliance Office:
Compliance Officer (HIPAA Program)
SYNC Life
17650 Highland Road Suite E, Baton Rouge, LA 70810
Phone: (225) 425-7962
Email: privacy@synclife.health

U.S. Department of Health and Human Services:
Office for Civil Rights (OCR)
200 Independence Avenue, S.W.
Washington, D.C. 20201
Website: https://www.hhs.gov/hipaa/filing-a-complaint/index.html

SYNC Life strictly prohibits any retaliation or penalty against you for filing a complaint or exercising your privacy rights.

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that:

1. You consent to treatment at this office (or any other satellite office under common ownership).
2. You intend this consent to remain effective after a specific diagnosis has been made and treatment recommended.

You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician, including the purpose, potential risks, and benefits of any test, treatment, or recommended course of action. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

Patient statement of consent

“I voluntarily request the health care provider(s) at this clinic to perform reasonable and necessary medical examination, testing, and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive, or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and understand the above statements and consent fully and voluntarily to them.”

For convenience of accessing care, our clinic offers remote telehealth consultations between patients and clinicians via a secure video platform. Additionally, your healthcare provider may consult with other providers or specialists remotely about your care via video or phone. Please carefully review this form and indicate your acceptance below.

Potential benefits of telehealth include:

• Convenience in accessing your providers from your home or another location.
• Protection against the transmission of communicable illnesses between yourself and other patients and clinic staff.
• Improvements to the quality of care when your clinician can consult with other providers as needed.

Inherent in the use of telehealth are technological risks of disruption to the call or video connection and other technical difficulties. You or the provider may discontinue the telehealth consultation if either of you determine that technical difficulties are too disruptive to continue.

We take strong precautions to safeguard the privacy of your protected health information (PHI), including using only HIPAA-compliant platforms for telehealth. Nevertheless, there is an unavoidable risk of unauthorized access when sending/receiving PHI electronically (for example, via a video feed). You are solely responsible for ensuring privacy and confidentiality on your side - by conducting the visit in a private space where others cannot overhear and cannot see private information on the screen. We do not record (voice or video) telehealth consultations, but the health care provider will retain a medical record of care in their secure electronic health records system.

Some visits - specifically, those that require the clinician to be physically present with you - are not suitable for telehealth. Your provider may ask that you schedule an in-person visit for any issues that require in-person evaluation or treatment. Telehealth is not a substitute for emergency care. If you need urgent care, call 911 or go to the nearest urgent care facility.

You are responsible for the cost of your telehealth consultation. If you are seeking insurance payment or reimbursement for the visit, note that insurance companies may require that you participate in the telehealth consultation from a hospital, a mental health facility, a physician's office, an adult care facility, or your home.

Consent to the Use of Telehealth

• I have read this form - or had it read and explained to me - in full. I fully understand its contents, including the risks, benefits, and alternatives.
• I have been given opportunity to ask questions and any questions have been answered to my satisfaction.

I hereby give my informed consent to the use of telehealth in the course of my diagnosis and treatment.