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.[1]

EZ Sleep Club is required by law to maintain the privacy of your health information. EZ Sleep Club is also required to provide you with a notice that describes EZ Sleep Club legal duties and privacy practices and your privacy rights with respect to your health information.[2] We will follow the privacy practices described in this notice.[3] If you have any questions about any part of this Notice or if you want more information about the privacy practices of EZ Sleep Club, please contact Andrea Ewert, CEO, PO Box 578173 Modesto, CA 95357.[4]

We reserve the right to change the privacy practices described in this notice in the event that the practices need to be changed to be in compliance with the law. We will make the new notice provisions effective for all the protected health information that we maintain. If we change our privacy practices, we will have them available upon request. It will also be posted at the location of service.[5]

EZ Sleep Club May Use or Disclose Your Health Information for Treatment, Payment of Health Care Operations[6]

The following categories describe the ways that EZ Sleep Club may use and disclose your health information. For each type of use and disclosure, we will explain what we mean and present some examples.

Treatment. We may use or disclose your health care information in the provision, coordination, or management of your health care. Our communications to you may be by telephone, cell phone, e-mail, patient portal, or by mail. For example, we may use your information to call and remind you of an appointment or to refer your care to another physician. If another provider requests your health information and they are not providing care and treatment to you, we will request an authorization from you before providing your information.

Payment. We may use or disclose your health care information to obtain payment for your health care services. For example, we may use your information to send a bill for your health care services to your insurer.

Health Care Operations. We may use or disclose your health care information for activities relating to the evaluation of patient care, evaluating the performance of health care providers, business planning and compliance with the law. For example, we may use your information to determine the quality of care you received when you had your surgery. If the activities require disclosure outside of our health care organization, we will request your authorization before disclosing that information.

How EZ Sleep Club May Use or Disclose Your Health Information Without Your Written Authorization[7]

The following categories describe the ways that EZ Sleep Club may use and disclose your health information without your authorization. For each type of use and disclosure, we will explain what we mean and present some examples.

1. Required by Law. We may use and disclose your health information when that use, or disclosure is required by law. For example, we may disclose medical information to report child abuse or to respond to a court order.
2. Public Health. We may release your health information to local, state, or federal public health agencies subject to the provisions of applicable state and federal law for reporting communicable diseases, aiding in the prevention or control of certain diseases and reporting problems with products and reactions to medications to the Food and Drug Administration.
3. Victims of Abuse, Neglect or Violence. We may disclose your information to a government authority authorized by law to receive reports of abuse, neglect or violence relating to children or the elderly.
4. Health Oversight Activities. We may disclose your health information to health agencies authorized by law to conduct audits, investigations, inspections, licensure, and other proceedings related to oversight of the health care system.
5. Judicial and Administrative Proceedings. We may disclose your health information in the course of an administrative or judicial proceeding in response to a court order. Under most circumstances when the request is made through a subpoena, a discovery request or involves another type of administrative order, your authorization will be obtained before disclosure is permitted.
6. Law Enforcement. We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, or missing person, or complying with a court order or other law enforcement purposes. Under some limited circumstances we will request your authorization prior to permitting disclosure.
7. Coroners and Medical Examiners. We may disclose your health information to coroners and medical examiners. For example, this may be necessary to determine the cause of death.
8. Cadaveric, Organ, Eye or Tissue Donation. If we are a hospital, we may disclose your health information to organizations involved in procuring organs and tissues for transplantation.
9. Research. Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct medical research which may involve an assessment of how well a drug is working to cure a heart disease or whether a certain treatment is working better than another.
10. To Avert a Serious Threat to Health of Safety. We may disclose your health information in a very limited manner to appropriate persons to prevent a serious threat to the health or safety of a particular person or the general public. Disclosure is usually limited to law enforcement personnel who are involved in protecting the public safety.
11. Specialized Government Functions. Under certain and very limited circumstances, we may disclose your health care information for military, national security, or law enforcement custodial situations.
12. Workers’ Compensation. Both state and federal law allow the disclosure of your health care information that is reasonably related to a worker’s compensation injury to be disclosed without your authorization. These programs may provide benefits for work-related injuries or illness.
13. Health Information. We may use or disclose your health information to provide information to you about treatment alternatives or other health related benefits and services that may be of interest to you.
14. Directory. Unless you object, we may use your health information, such as your name, location in our facility, your general health condition (e.g., “stable,” or “unstable”), and your religious affiliation for our directory. It is our duty to give you enough information so you can decide whether or not to object to release of this information for our directory. The information about you contained in our directory will not be disclosed to individuals not associated with our health care environment without your authorization.

If you do not object and the situation is not an emergency, and disclosure is not otherwise prohibited by law, we are permitted to release your information under the following circumstances:

1. To individuals involved in your care—we may release your health information to a family member, other relative, friend or other person whom you have identified to be involved in your health care or the payment of your health care;
2. To family—we may use your health information to notify a family member, a personal representative, or a person responsible for your care, of your location, general condition, or death; and
3. To disaster relief agencies—we may release your health information to an agency authorized by law to assist in disaster relief activities.

15.  Health Information Availability After Death. The health care provider may use or disclose information without your  authorization
50 years after the date of your death. If you wish to restrict such use and disclosure, please see “Request Restrictions on Certain
Uses and Disclosures” below.

When EZ Sleep Club is Required to Obtain an Authorization to Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, we will not use or disclose your health information without written authorization from you. For example, uses and disclosures made for the purpose of psychotherapy, marketing and the sale of protected health information require your authorization. If your provider intends to engage in fundraising, you have the right to opt out of receiving such communications. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. If you revoke your authorization, we will no longer be able to use or disclose health information about you for the reasons covered by your written authorization, though we will be unable to take back any disclosures we have already made with your permission.

Your Health Information Rights

1. 1. 1. Inspect and Copy Your Health Information. You have the right to inspect and obtain a copy of your health care information. You have the right to request that the copy be provided in an electronic form or format (e.g., PDF saved onto CD). If the form and format are not readily producible, then the organization will work with you to provide it in a reasonable electronic form or format. For example, you may request a copy of your immunization record from your health care provider. This right of access does not apply to psychotherapy notes, which are maintained for the personal use of a mental health professional. Your request for inspection or access must be submitted in writing to: Andrea Ewert, CEO EZ Sleep Club, PO Box 578173 Modesto CA 95357 (888) 588-0202. In addition, we may charge you a reasonable fee to cover our expenses for copying your health information.
      2. Request to Correct Your Health Information. You have a right to request that EZ Sleep Club amend your health information that you believe is incorrect or incomplete. For example, if you believe the date of you heart surgery is incorrect; you may request that the information be corrected. We are not required to change your health information and if your request is denied, we will provide you with information about our denial and how you can disagree with the denial. To request an amendment, you must make you request in writing to Andrea Ewert, CEO, PO Box 578173 Modesto, CA 95357. You must also provide a reason for your request.
      3. Request Restrictions on Certain Uses and Disclosures. You have the right to request restrictions on how your health information is used or to whom your information is disclosed, even if the restriction affects your treatment or our payment or health care operation activities. For example, if you are an employee in a clinic and you receive health care services in that clinic, you may request that your medical record not be stored with the other clinic records. However, we are not required to agree in all circumstances to your requested restrictions, except in the case of a disclosure restricted to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and the protected health information pertains solely to a health care item or service for which you, or the person other than the health plan on your behalf, has paid the covered entity in full. If you would like to make a request for restrictions, you must submit your request in writing to [include title of contact person and address].
      4. Receive Confidential Communications Of Health Information. You have the right to request that we communicate your health information to you in different ways or places. For example, you may wish to receive information about your health status in a special, private room or through a written letter sent to a private address. We must accommodate reasonable requests.

To request confidential communications, you must submit your request in writing to Andrea Ewert, CEO, PO Box 578173 Modesto, CA 95357.

1. 1. 1. Receive A Record of Disclosures Of Your Health Information. You have the right to request a list of the disclosures of your health information that we have made in compliance with federal and state law. This list will include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and why the disclosure was made. For some types of disclosures, the list will also include the date and time the request for disclosure was received and the date and time the disclosure was made.

For example, you may request a list that indicates all the disclosures your health care provider has made from your health care record in the past six months. To request this accounting of disclosures, you must submit your request in writing to Andrea Ewert, CEO, PO Box 578173 Modesto, CA 95357. We must comply with your request for a list within 60 days, unless you agree to a 30-day extension, and we may not charge you for the list, unless you request such list more than once per year.

1. 1. 1. Obtain A Paper Copy of This Notice. Upon your request, you may at any time receive a paper copy of this notice, even if you earlier agreed to receive this notice electronically. To obtain a paper copy of this Notice, please visit our website at www.ezsleepclub.com.
      2. Notified of a Breach. Your provider is required by law to maintain the privacy of protected health information and provide you with notice of its legal duties and privacy practices with respect to protected health information and to notify you following a breach of unsecured protected health information.
      3. Complaint. If you believe your privacy rights have been violated, you may file a complaint with Andrea Ewert, CEO, PO Box 578173 Modesto, CA 95357. He will provide you with any needed assistance. We request that you file your complaint in writing so that we may better assist in the investigation of your complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services. If your complaint relates to your privacy rights while you were receiving treatment for mental illness, alcohol or drug abuse or a developmental disability you may also file a complaint with the staff or administrator of the treatment facility or community mental health program. There will be no retaliation against you in any way for filing a complaint.[8]

If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact Andrea Ewert, CEO, PO Box 578173 Modesto, CA 95357.

A website that provides information about our customer service, privacy policy and benefits can be found at www.ezsleepclub.com.

Effective Date of This Notice: September 23rd, 2013

[1] 45 CFR 164.520(b)(1)(i)

[2] 45 CFR 164.520(b)(1)(v)(A)

[3] 45 CFR 164.526(b)(1)(v)(B)

[4] 45 CFR 164.520((b)(1)(vii)

[5] 45 CFR 164.526(b)(1)(v)(C)

[6] 45 CFR 164.526(b)(1)(ii)(A-D)

[7] 45 CFR 164.5269b)(1)(ii)(B-D)

[8] 45 CFR 164.520(b)(1)(vi); Wis. Stat. 51.61(1)(u)

We believe that all patients receiving services from EZ Sleep Club should be informed of their rights. Therefore, you are entitled to:

PATIENT RESPONSIBILITIES

• Patient agrees to request payment of authorized Medicare, Medi-cal, or other private insurance benefits are paid directly to EZ Sleep Club for any services furnished by EZ Sleep Club.
• Patient agrees to accept all financial responsibility for services furnished by EZ Sleep Club
• Patient agrees that any legal fees resulting from a disagreement between the parties shall be borne by the unsuccessful party in any legal action taken.

When the patient is unable to make medical or other decisions, the family should be consulted for direction.

All staff members will understand and be able to discuss the Patient Bill of Rights and Responsibilities with the patient and caregiver(s). Each staff member will receive training during orientation and attend an annual in-service education class on the Patient Bill of Rights and Responsibilities.

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
It is our duty to maintain the privacy and confidentiality of your protected health information (PHI). We will create records regarding your and the treatment
and service we provide to you. We are required by law to maintain the privacy of your PHI, which includes any individually identifiable information that we obtain from you or others that relates to your past, present or future physical or mental health, the health care you have received, or payment for your health care. We will share protected health information with one another, as necessary, to carry out treatment, payment or health care operations relating to the services to be rendered at the company.

As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of PHI. This notice also discusses the uses and disclosures we will make of your PHI. We must comply with the provisions of this notice as currently in effect, although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all PHI we maintain. You can always request a written copy of our most current privacy notice from our Privacy Officer.

PERMITTED USES AND DISCLOSURES
We can use or disclose your PHI for purposes of treatment, payment and health care operations. For each of these categories of uses and disclosures, we have provided a description and an example below. However, not every particular use or disclosure in every category will be listed.

Treatment means providing services as ordered by your physician. Treatment also includes coordination and consultations with other health care providers relating to your care and referrals for health care from one health care provider to another. We may also disclose PHI to outside entities performing other services related to your treatment such as hospital, diagnostic laboratories, home health or hospice agencies, etc.

Payment means the activities we undertake to obtain reimbursement for the health care provided to you, including billing, collections, claims management, prior approval, determinations of eligibility and coverage and other utilization review activities. Federal or state law may require us to obtain a written release from you prior to disclosing certain specially protected PHI for payment purposes, and we will ask you to sign a release when necessary under applicable law.

Health care operations means the support functions of the company, related to treatment and payment, such as quality assurance activities, case management, receiving and responding to patient comments and complaints, physician reviews, compliance programs, audits, business planning, development, management and administrative activities. We may use your PHI to evaluate the performance of our staff when caring for you. We may also combine PHI about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments
are effective. We may also disclose PHI for review and learning purposes. In addition, we may remove information that identifies you so that others can use the de-identified information to study health care and health care delivery without learning who you are.

OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

We may also use your PHI in the following ways:

• To provide appointment reminders for treatment or medical care.
• To tell you about or recommend possible treatment alternatives or other health-related benefits and services that may be of interest to you.
• To disclose to your family or friends or any other individual identified by you to the extent directly related to such person’s involvement in your care or the payment for your care. We may use or disclose your PHI to notify, or assist in the notification of, a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. If you are available, we will give you an opportunity to object to these disclosures, and we will not make these disclosures if you object. If you are not available, we will determine whether
  a disclosure to your family or friends is in your best interest, taking into account the circumstances and based upon our professional judgment.

When permitted by law, we may coordinate our uses and disclosures of PHI with public or private entities authorized by law or by charter to assist in disaster relief efforts.

We will allow your family and friends to act on your behalf to pick up filled prescriptions, medical supplies, X-rays, and similar forms of PHI, when we determine, in our professional judgment that it is in your best interest to make such disclosures.

We may contact you as part of our fundraising and marketing efforts as permitted by applicable law. You have the right to opt out of receiving such fundraising communications.

We may use or disclose your PHI for research purposes, subject to the requirements of applicable law. For example, a research project may involve comparisons of the health and recovery of all patients who received a particular medication. All research projects are subject to a special approval process which balances research needs with a patient’s need for privacy. When required, we will obtain a written authorization from you prior to using your health information for research.

We will use or disclose PHI about you when required to do so by applicable law.

In accordance with applicable law, we may disclose your PHI to your employer if we are retained to conduct an evaluation relating to medical surveillance of your workplace or to evaluate whether you have a work-related illness or injury. You will be notified of these disclosures by your employer or the company as required by applicable law.

Note: incidental uses and disclosures of PHI sometimes occur and are not considered to be a violation of your rights. Incidental uses and disclosures are by-products of otherwise permitted uses or disclosures which are limited in nature and cannot be reasonably prevented.

SPECIAL SITUATIONS
Subject to the requirements of applicable law, we will make the following uses and disclosures of your PHI:

Organ and Tissue Donation. If you are an organ donor, we may release PHI to organizations that handle organ procurement or transplantation as necessary
to facilitate organ or tissue donation and transplantation.

Military and Veterans. If you are a member of the Armed Forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.

Worker’s Compensation. We may release PHI about you for programs that provide benefits for work-related injuries or illnesses.

Public Health Activities. We may disclose PHI about you for public health activities, including disclosures:

• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report child abuse or neglect;
• to persons subject to the jurisdiction of the Food and Drug Administration (FDA) for activities related to the quality, safety, or effectiveness of FDA-regulated products or services and to report reactions to medications or problems with products;
• 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 that an adult patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if the patient agrees or when required or authorized by law.

Health Oversight Activities. We may disclose PHI to federal or state agencies that oversee our activities (e.g., providing health care, seeking payment, and civil rights).

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI subject to certain limitations.

Law Enforcement. We may release PHI if asked to do so by a law enforcement official:

• In response to a court order, warrant, summons or similar process;
• To identify or locate a suspect, fugitive, material witness, or missing person;
• About the victim of a crime under certain limited circumstances;
• About a death we believe may be the result of criminal conduct;
• About criminal conduct on our premises; or
• In emergency circumstances, to report a crime, the location of the crime or the victims, or the identity, description or location of the person who
  committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may release PHI to a coroner or medical examiner. We may also release PHI about patients to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities. We may release PHI about you to authorized federal officials for intelligence, counterintelligence, other national security activities authorized by law or to authorized federal officials so they may provide protection to the President or foreign heads of state.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release PHI about you to the correctional institution or law enforcement official. This release would be necessary (1) to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Serious Threats. As permitted by applicable law and standards of ethical conduct, we may use and disclose PHI if we, in good faith, believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public or is necessary for law enforcement authorities to identify or apprehend an individual.

Note: HIV-related information, genetic information, alcohol and/or substance abuse records, mental health records and other specially protected health information may enjoy certain special confidentiality protections under applicable state and federal law. Any disclosures of these types of records will be subject to these special protections.

OTHER USES OF YOUR HEALTH INFORMATION
Certain uses and disclosures of PHI will be made only with your written authorization, including uses and/or disclosures: (a) of psychotherapy notes (where
appropriate); (b) for marketing purposes; and (c) that constitute a sale of PHI under the Privacy Rule. Other uses and disclosures of PHI not covered by
this notice or the laws that apply to us will be made only with your written authorization. You have the right to revoke that authorization at any time, provided
that the revocation is in writing, except to the extent that we already have taken action in reliance on your authorization.

YOUR RIGHTS
You have the right to request restrictions on our uses and disclosures of PHI for treatment, payment and health care operations. However, we are not required to agree to your request unless the disclosure is to a health plan in order to receive payment, the PHI pertains solely to your health care items or services for which you have paid the bill in full, and the disclosure is not otherwise required by law. To request a restriction, you may make your request in writing to the Privacy Officer.

You have the right to reasonably request to receive confidential communications of your PHI by alternative means or at alternative locations. To make such a request, you may submit your request in writing to the Privacy Officer.

You have the right to inspect and copy the PHI contained in our company records, except:

• for psychotherapy notes, (i.e., notes that have been recorded by a mental health professional documenting counseling sessions and have been separated from the rest of your medical record);
• for information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding;
• for PHI involving laboratory tests when your access is restricted by law;
• if you are a prison inmate, and access would jeopardize your health, safety, security, custody, or rehabilitation or that of other inmates, any officer, employee, or other person at the correctional institution or person responsible for transporting you;
• if we obtained or created PHI as part of a research study, your access to the PHI may be restricted for as long as the research is in progress, provided that you agreed to the temporary denial of access when consenting to participate in the research;
• for PHI contained in records kept by a federal agency or contractor when your access is restricted by law; and
• for PHI obtained from someone other than us under a promise of confidentiality when the access requested would be reasonably likely to reveal the source of the information.

In order to inspect or obtain a copy your PHI, you may submit your request in writing to the Medical Records Custodian. If you request a copy, we may charge you a fee for the costs of copying and mailing your records, as well as other costs associated with your request.

We may also deny a request for access to PHI under certain circumstances if there is a potential for harm to yourself or others. If we deny a request for access for this purpose, you have the right to have our denial reviewed in accordance with the requirements of applicable law.

4. You have the right to request an amendment to your PHI but we may deny your request for amendment, if we determine that the PHI or record that is the subject of the request:

• was not created by us, unless you provide a reasonable basis to believe that the originator of PHI is no longer available to act on the requested amendment;
• is not part of your medical or billing records or other records used to make decisions about you;
• is not available for inspection as set forth above; or
• is accurate and complete.

In any event, any agreed upon amendment will be included as an addition to, and not a replacement of, already existing records. In order to request an amendment to your PHI, you must submit your request in writing to Medical Record Custodian at our company, along with a description of the reason for your request.

5. You have the right to receive an accounting of disclosures of PHI made by us to individuals or entities other than to you for the six years prior to your request, except for disclosures:

(i) to carry out treatment, payment and health care operations as provided above;
(ii) incidental to a use or disclosure otherwise permitted or required by applicable law;
(iii) pursuant to your written authorization;

• to persons involved in your care or for other notification purposes as provided by law;
• for national security or intelligence purposes as provided by law;
• to correctional institutions or law enforcement officials as provided by law;
• as part of a limited data set as provided by law.

To request an accounting of disclosures of your PHI, you must submit your request in writing to the Privacy Officer at our company. Your request must state a specific time period for the accounting (e.g., the past three months). The first accounting you request within a twelve (12) month period will be free.

For additional accountings, we may charge you for the costs of providing the list. We will notify you of the costs involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.

6. You have the right to receive a notification, in the event that there is a breach of your unsecured PHI, which requires notification under the Privacy Rule.

COMPLAINTS
If you believe that your privacy rights have been violated, you should immediately contact the sleep center’s Privacy Officer. We will not take action against you for filing a complaint. You also may file a complaint with the Secretary of the U. S. Department of Health and Human Services, 200 Independence Ave. S.W., Washington DC, 20201.

Grievance / Complaint Reporting

You may lodge a complaint without concern for reprisal, discrimination, or unreasonable interruption of service.
To place a grievance, please call (888) 588-0202 and speak to management.
If your complaint is not resolved to your satisfaction within 5 working days, you may initiate a formal grievance, in writing and forward it to the executive team.
You can expect a written response within 14 working days or receipt.

You may also make inquiries or complaints about this sleep center by calling Medicare at 1-800-MEDICARE and/or
the Accreditation Commission for Health Care (ACHC) at 919-785-1214.