HIPAA Policy and Acknowledgment of Receipt of Notice of Privacy Practices

The Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (together, HIPAA) provide safeguards to protect your privacy. This is an abbreviated summary. Our full Notice of Privacy Practices appears below and is available at our offices. The complete text of the HIPAA regulations is available on the website of the U.S. Department of Health and Human Services (HHS) at www.hhs.gov.

HIPAA establishes rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not prevent the normal exchange of information necessary to provide you with medical services, to obtain payment for those services, or to carry out our health care operations.

We will protect the confidentiality of your information and will use and disclose it only as permitted or required by law. This includes sharing information as necessary for treatment, payment, and health care operations, such as with other health care providers involved in your care, laboratories, and health plans or other payers, as described in our Notice of Privacy Practices below.

We maintain administrative, physical, and technical safeguards designed to protect the confidentiality, integrity, and availability of your electronic PHI, including the information in our Electronic Medical Record (EMR) system. Information that has been de-identified in accordance with HIPAA may be used in retrospective studies. Studies requiring personal identifiers will require your written authorization, unless the law otherwise permits.

It is our policy to remind patients of their appointments. We may do this by telephone, text message, e-mail, or U.S. mail, using the contact information you provide to us, consistent with any confidential communication preferences you request, and, where the law requires, with your consent to receive those communications. We may also contact you about treatment alternatives, changes to our policies, and health-related products and services that we offer. We will obtain your written authorization before sending any communication that HIPAA treats as marketing, including any communication for which a third party pays us.

We will provide patients with access to their records in accordance with state and federal law. You understand that government agencies and health plans may inspect our offices and review documents that include PHI in the normal performance of their duties, as the law permits.

You have the right to request restrictions on the use and disclosure of your protected health information as described in our Notice of Privacy Practices. We do not sell your PHI.

Passport Health offers an online appointment scheduling portal as a convenience to our patients and to others, such as parents, who are involved in their care. We maintain administrative, physical, and technical safeguards designed to protect your PHI, including information you submit through the portal. No method of electronic transmission or storage is completely secure, and we encourage you to include only the information needed to schedule your appointment. If you prefer, you may call to book your appointment over the phone.

Our website may use cookies and similar technologies to operate the site, maintain its security, and understand how it is used. You can view our full Privacy Statement here. We do not use tracking technologies on our appointment scheduling portal, or on other pages that collect your PHI, in a manner that discloses your PHI to third parties for advertising or marketing purposes. We do not sell your PHI. We will not disclose your PHI to any affiliate of us or vendor of ours except for a necessary purpose, and only when that affiliate or vendor has executed a written agreement with us requiring them to protect that PHI as HIPAA requires.

Your signature, including an electronic signature, acknowledges that you have received our Notice of Privacy Practices. Signing this acknowledgment does not waive any right you have under HIPAA or state law.

NOTICE OF PRIVACY PRACTICES OF PASSPORT HEALTH

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. We Have A Legal Duty To Safeguard Your Protected Health Information (PHI)

   This notice applies to all Passport Health locations and to the members of the Passport Health workforce.

   We are legally required to protect the privacy of health information that may reveal your identity. This information is commonly referred to as “protected health information,” or “PHI” for short. It includes information that can be used to identify you that we have created or received about your past, present or future health or condition, the provision of health care to you, or the payment of this health care. We must provide you with this notice about our privacy practices that explains how, when and why we use and disclose your PHI.

   When we use, disclose, or request your PHI, we will make reasonable efforts to limit it to the minimum necessary to accomplish the purpose, except where the law does not require that standard, such as disclosures to other providers for treatment. We are legally required to follow the privacy practices that are described in this notice.

   We are also required to notify you if there is a breach of your unsecured PHI, and we will do so as the law requires.

   We reserve the right to change the terms of this notice and our privacy policies at any time, as the law permits. Any new terms will apply to all PHI we maintain, including PHI we created or received before the change. When we make a material change to our privacy practices, we will promptly revise this notice, post the revised notice on our website and at our locations, and make it available to you upon request. You can also request a copy of this notice at any time from the contact person listed in Section V below, by calling our office.

2. How We May Use And Disclose Your Protected Health Information

   We use and disclose health information for many different reasons. For some of these uses or disclosures, we need your written authorization. Below we describe the different categories of our uses and disclosures and give you some examples of each category.

   During your intake, prior to receiving any health care services, you will be asked to sign a statement acknowledging that you have received this notice. HIPAA permits Passport Health and its medical staff to use and disclose your health information for purposes of treatment, payment and health care operations without your authorization. A description of each of these uses follows.

   Uses and Disclosures Relating to Treatment, Payment or Health Care Operations.

   We may use and disclose your PHI for the following reasons:

   • For treatment. We may disclose your PHI to physicians, nurses, medical students, and other health care personnel who provide you with health care services or are involved in your care.
   • To obtain payment for treatment. We may use and disclose your PHI in order to bill and collect payment for the treatment and services provided to you. For example, we may provide portions of your PHI to our billing department and your health plan to get paid for the health care services we provided to you. We may also provide your PHI to our business associates, such as billing companies, claims processing companies and others that process our health care claims or provide services on our behalf, or provide services directly to you.
   • For health care operations. We may disclose your PHI in order to operate our health care delivery system. For example, we may use your PHI in order to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided health care services to you. We may also provide your PHI to our accountants, attorneys, consultants and others in order to make sure we’re complying with the laws that affect us.

   To the extent we disclose your PHI to contractors, agents and other business associates who need the information in order to assist us with obtaining payment or carrying out our business operations, we will have a written contract to ensure that our business associate also protects the privacy of your PHI.

   Other Uses And Disclosures That Do Not Require Your Written Authorization.

   We may use and disclose your PHI without your written authorization for the following reasons:

   • When a disclosure is required by federal, state or local law, judicial or administrative proceedings or law enforcement. For example, we make disclosures when a law requires that we report information to government agencies and law enforcement personnel about victims of abuse, neglect or domestic violence; when dealing with gunshot and other wounds; or when ordered in a judicial or administrative proceeding.
   • For public health activities. For example, we report information about births, deaths and various diseases to government officials in charge of collecting that information. We may also report immunizations and related information to state and local immunization registries, subject to any right you have under state law to opt out of that reporting, and we may notify a person who may have been exposed to a communicable disease or who may otherwise be at risk of contracting or spreading a disease or condition, as the law authorizes. Where state or other law requires a school to have proof of immunization, we may disclose proof of immunization to the school if you, or your parent or guardian, agree.
   • Victims of Abuse, Neglect or Domestic Violence. We may release your PHI to a public health authority that is authorized to receive reports of abuse, neglect or domestic violence. For example, we may report your information to government officials if we reasonably believe that you have been a victim of abuse, neglect or domestic violence. We will make every effort to obtain your permission before releasing this information, but in some cases we may be required or authorized to act without your permission.
   • For health oversight activities. For example, we will provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization.
   • To family members, friends, and others involved in your care or payment. We may disclose PHI to a family member, relative, close friend, or other person you identify who is involved in your care or in payment for your care, limited to the PHI directly relevant to that person’s involvement. For example, we may discuss your vaccination schedule with a parent or travel companion who accompanies you to your appointment. If you are present and able to agree or object, we will give you the opportunity to do so before we make the disclosure. If you are not present or are unable to agree or object, we may use our professional judgment to decide whether the disclosure is in your best interest. For a minor, we may disclose PHI to a parent, guardian, or other person acting in place of a parent, as the law permits.
   • Product Monitoring, Repair and Recall. We may disclose your information to a person or company that is required by the Food and Drug Administration to: (1) report or track product defects or problems; (2) repair, replace or recall defective or dangerous products; or (3) monitor the performance of a product after it has been approved for use by the general public.
   • Lawsuits and Disputes. We may disclose your PHI if we are ordered to do so by a court or administrative tribunal that is handling a lawsuit or other dispute. We may also disclose your PHI in response to a subpoena or discovery request if we receive the assurances the law requires.

   • Law Enforcement. We may disclose your PHI to law enforcement officials for any of the following reasons:

     • To comply with court orders or laws that we are required to follow;
     • To assist law enforcement officers with identifying or locating a suspect, fugitive, witness or missing person;
     • If you have been the victim of a crime and we determine that: (1) we have been unable to obtain your consent because of any emergency or your incapacity; (2) law enforcement officials need the information immediately to carry out their law enforcement duties; and (3) in our professional judgment disclosure to these officers is in your best interests;
     • If we suspect a patient’s death resulted from criminal conduct;
     • If necessary to report a crime that occurred on our property; or
     • If necessary to report a crime discovered during an offsite medical emergency (for example, by emergency medical technicians at the scene of a crime).
   • Military and Veterans. If you are in the Armed Forces, we may disclose your PHI to appropriate military command authorities for activities they deem necessary to carry out their military mission. We may also release health information about foreign military personnel to the appropriate foreign military authority.
   • Inmates and Correctional Institutions. If you are an inmate or you are detained by a law enforcement officer, we may disclose your PHI to the prison officers or law enforcement officers if necessary to provide you with health care, or to maintain safety, security and good order at the place where you are confined. This includes sharing information that is necessary to protect the health and safety of other inmates or persons involved in supervising or transporting inmates.
   • Coroners, Medical Examiners and Funeral Directors. In the unfortunate event of your death, we may disclose your PHI to a coroner or medical examiner. This may be necessary, for example, to determine the cause of death. We may also release this information to funeral directors as necessary to carry out their duties.
   • For purposes of organ donation. We may notify organ procurement organizations to assist them in organ, eye or tissue donation and transplants.
   • For research purposes. In most cases, we will ask for your written authorization before using your PHI for research purposes. However, in certain, limited, circumstances, we may use and disclose your PHI without consent or authorization if we obtain approval through a special process to ensure that such research poses little risk to your privacy. In any case, we would never allow researchers to use your name or identity publicly. We may also release your health information without your written authorization to people who are preparing for a future research project, so long as no personally identifiable information leaves our facility.
   • To avoid harm. In order to avoid a serious threat to the health or safety of a person or the public, we may provide PHI to law enforcement personnel or persons able to prevent or lessen such harm.
   • For specific government functions. We may disclose PHI of military personnel and veterans in certain situations. And we may disclose PHI for national security purposes, such as protecting the president of the United States or conducting intelligence operations.
   • For workers’ compensation purposes. We may provide PHI in order to comply with workers’ compensation laws.
   • Appointment reminders and health-related benefits or services. We may use PHI to provide appointment reminders or give you information about treatment alternatives or other health care services or benefits we offer or provide.
   • De-identified Information. We may also use or disclose information that has been de-identified in accordance with HIPAA, so that it cannot reasonably be used to identify you.
   • Incidental Disclosures. While we will take reasonable steps to safeguard the privacy of your PHI, certain disclosures of your PHI may occur during, or as an unavoidable result of our otherwise permissible uses or disclosures of your health information. For example, during the course of a treatment session, other patients in the treatment area may see, or overhear discussion of, your PHI.
   • State Law. Some state laws provide greater privacy protection or greater patient rights than HIPAA. Where a more protective state law applies, we will follow that law in using and disclosing your PHI, and you may have additional rights under that law. Because we provide care in many states, these laws vary by location and may affect, among other things: reporting of immunizations and other information to state and local immunization registries, including any right to opt out; disclosure of immunization and vaccination records to schools, employers, and others; the age at which a minor may consent to care, and the rights of parents and guardians to information about a minor patient; reporting of communicable diseases; the handling of laboratory and screening results and of sensitive health information, such as HIV status and sexually transmitted infections; patient access to records, including response times and fees; and responses to subpoenas and requests from law enforcement.

   Other Uses and Disclosures Require Your Prior Written Authorization.

   Most uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI require your written authorization, except in the limited circumstances HIPAA allows. We do not sell PHI. We will also obtain your written authorization for any other use or disclosure that this notice does not describe.

   If you choose to sign an authorization to disclose your PHI, you can later revoke that authorization in writing to stop any future uses and disclosures (to the extent that we have not taken any actions relying on the authorization).

3. What Rights You Have Regarding Your PHI

   You have the following rights with respect to your PHI:

   • The Right to Request Limits on Uses and Disclosures of Your PHI.
     You have the right to ask that we limit how we use and disclose your PHI. We will consider your request, but except as described in the next sentence, we are not legally required to accept it. We must agree to your request to restrict disclosure of your PHI to a health plan for purposes of payment or health care operations (but not treatment) if the PHI relates solely to a health care item or service for which you, or someone other than the health plan on your behalf, have paid us in full, unless the law requires the disclosure. If we accept any other request, we will document the limits and abide by them except in emergency situations. You may not limit the uses and disclosures that we are legally required or allowed to make.

   • The Right to Choose How We Send PHI to You.
     You have the right to ask that we send information to you at an alternate address or by alternate means. We will accommodate reasonable requests, and we will not ask you to explain the reason for your request.

   • The Right to See and Get Copies of Your PHI.
     In most cases, you have the right to look at or get copies of your PHI that we have, but you must make the request in writing. If we don’t have your PHI but we know who does, we will tell you how to get it. We will respond to you within 30 days after receiving your written request, and we may extend that period once by up to 30 days if we notify you in writing of the reason for the delay and the date by which we will respond. In certain situations, we may deny your request. If we do, we will tell you, in writing, our reasons for the denial and explain your right to have the denial reviewed.

     If we maintain your PHI electronically, you have the right to request an electronic copy in the form and format you request, if we can readily produce it in that form and format. You may also direct us to send a copy of your PHI to another person you designate, if your request is in writing, signed by you, and clearly identifies the designated person and where to send the copy. If you request copies of your PHI, we may charge you a reasonable, cost-based fee, as the law permits. Instead of providing the PHI you requested, we may provide you with a summary or explanation of the PHI as long as you agree to that and to the associated cost in advance.

   • The Right to Get a List of the Disclosures We Have Made.
     You have the right to get a list of instances in which we have disclosed your PHI. The list will not include disclosures made for treatment, payment or health care operations, disclosures made directly to you or under your authorization, disclosures to family members or others involved in your care, or incidental disclosures. The list also won’t include disclosures made for national security purposes, or to correctional institutions or law enforcement personnel as the law provides.

     Your request must state a time period for the disclosures you want us to include. We will ordinarily respond within 60 days of receiving your request, and we may extend that period once by up to 30 days if we notify you in writing of the reason for the delay. The list we will give you will include disclosures made in the six years before the date of your request unless you request a shorter time. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed and the reason for the disclosure. We will provide the first list you request in any 12-month period at no charge. If you make more than one request in the same 12-month period, we may charge you a reasonable, cost-based fee for each additional request, and we will tell you the fee in advance so that you may withdraw or modify your request.

   • The Right to Correct or Update Your PHI.
     If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that we correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. We will respond within 60 days of receiving your request, and we may extend that period once by up to 30 days if we notify you in writing of the reason for the delay. We may deny your request in writing if the PHI is (i) accurate and complete, (ii) not created by us, unless the person or entity that created it is no longer available to make the amendment, (iii) not part of the records we use to make decisions about you, or (iv) not information that you would be permitted to inspect and copy. Our written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don’t file one, you have the right to request that your request and our denial be attached to all future disclosures of your PHI. If we approve your request, we will make the change to your PHI, tell you that we have done it and tell others that need to know about the change to your PHI.

   • The Right to Get This Notice by E-Mail or on Paper.
     You have the right to get a copy of this notice by e-mail. Even if you have agreed to receive notice via e-mail, you also have the right to request a paper copy of this notice.

   • The Right to Choose Someone to Act for You.
     If you have given someone medical power of attorney, or if someone is your legal guardian, that person may exercise your rights and make choices about your PHI. A parent, guardian, or other person with legal authority may also act for a minor patient to the extent the law permits. We will confirm that the person has this authority before we take any action.

4. How To Complain About Our Privacy Practices

   If you think we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may file a complaint with the person listed in Section V below. You also may file a complaint with the Secretary of the U.S. Department of Health and Human Services by visiting www.hhs.gov/ocr/complaints, or by sending a written complaint to:

   Office for Civil Rights, U.S. Department of Health and Human Services
   200 Independence Avenue, S.W., Room 509F, HHH Building
   Washington, D.C. 20201

   Toll-free telephone number: 1-800-368-1019
   TDD: 1-800-537-7697

   We will take no retaliatory action against you if you file a complaint about our privacy practices.

5. Person To Contact For Information About This Notice Or To Complain About Our Privacy Practices

   If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the U.S. Department of Health and Human Services, please contact our Privacy Officer:

   E-mail: privacy@passporthealthusa.com
   Telephone: 888-499-7277
   Mailing Address:
   Passport Health
   Attention: Privacy Officer
   4343 E. Outlier Blvd.
   Suite 100W
   Phoenix, AZ 85008

6. Effective Date Of This Notice

   This notice is effective as of October 21, 2026