Elixir Waiver | danceteamunion

Cancellation: If at any time a membership is canceled and a member returns to join again, full enrollment and current monthly installment rates will apply and new terms will apply. Any prior payments and discounts are forfeited at the time of cancellation. A 60-day cancellation notice is permitted after the initial term is fulfilled. If immediate cancellation is needed before the initial term is fulfilled, a $99 immediate cancel fee will be due and no further services nor access will be granted once canceled.

CUSTOMER'S RIGHT TO CANCEL

(A) BUYER MAY CANCEL THIS CONTRACT BY SENDING NOTICE OF YOUR WISH TO CANCEL; All cancellations must be done through the members portal

Non-Transferability and Non-Refundability of Purchased Sessions

Non-Transferability: The rights to any purchased sessions are strictly limited to the individual or entity identified at the time of purchase. Such sessions shall not be transferable, assignable, or applicable to any other individual, entity, or purpose beyond the original intent for which they were acquired.

Non-Refundability: All sales of sessions are final, and no refunds, credits, or exchanges shall be granted under any circumstances. This includes, but is not limited to, cases involving unused, partially used, or expired sessions.

Expiration of Sessions: Any sessions not utilized within the prescribed period of validity, if such a period is specified, shall be deemed forfeited. No refunds, credits, or remedies shall be issued for forfeited sessions.

Acknowledgment: By executing this agreement, the purchaser expressly acknowledges, agrees to, and accepts these terms, including the limitations on transferability and non-refundability of purchased sessions, as binding and enforceable.

PAYMENT TERMS & CONDITIONS

AUTO-RENEWAL: The following is a membership term, this membership agreement will renew and automatically continue on a month-to-month basis at the program installment amount listed above. This auto-renewal can be canceled with a 60-day notice, submitted in person at the facility, or submitted via certified mail to the location where the member is enrolled. Any outstanding balances plus any monthly program installments scheduled during the 60-day notice period will be due in full at the time of cancellation to satisfy the cancellation policy. The program installment rate listed in this agreement may be increased up to 5% per calendar year after the initial term is satisfied.

Delinquent/un-collectible program installment payments: In the event, the buyer's automated payments are returned unpaid for reasons including but not limited to non-sufficient funds, closed account, declines, or the like, the buyer will be assessed a reasonable return fee not to exceed limited set forth by applicable state law. This return fee will be debited from the buyer's bank account or other form of payment provided on the member's file in addition to the uncollected balance(s).

Lapse in member use: All payment installments including applicable return fees must be made regardless of services used.

Installment Freeze Provisions: Buyer may request to freeze the membership in person or in writing sent through certified mail where the membership was purchased. Freeze requests will be granted in calendar month increments, not exceeding 1 month. During the frozen period, a $20/month freeze fee will continue to be billed on the same installment date listed above. Access to the studio will not be permitted via a non-non-staffed entry system during frozen months. If the member elects to freeze longer than 1 month, he/she must submit this request in writing and may receive confirmation of approval for the extension.

Refunds and Transfer of Services: Memberships, packages, and sessions are non-refundable and not transferrable. Only the buyer/member is authorized access to the facility and to use the active services on the account as outlined in this agreement.

Oral Statements: No oral or written promises or statements made by staff or other members of Elixir Muscle Recovery Centers are part of this contract.

MEMBERSHIP TERMS AND CONDITIONS.

Members agree to abide by all rules and regulations as posted by Elixir Muscle Recovery, or any document provided to the member. In the case of a minor, the member (or the legal guardian) also acknowledges reading and voluntarily agreeing to the Release of Liability Waiver. Failure of any member to comply with this membership agreement or any rule or regulation shall be cause for revocation of membership without notice and any liability or refund. This membership agreement is cancelable only as provided by state law, otherwise, the entire amount of the Membership Agreement is due per the terms of this agreement. There will be no refund of prepaid membership fees. Upon default by the buyer, Elixir Muscle Recovery, may at its option, declare all unpaid total payments immediately due and payable without demand or notice. Waiver of any default by Buyer shall not operate as a waiver of future defaults. Elixir Muscle Recovery shall be entitled to all actual and reasonable costs of collection, including reasonable attorney fees, upon default by the buyer If a Member's sole and only remedy in the event of a breach by Elixir Muscle Recovery of the terms and conditions of the contract, a payment default, or a breach of any of its warranties or representations shall be canceled as otherwise provided herein, or as provided by law, Elixir Muscle Recover may assign the Buyer's payment obligation to an affiliated company, any bank, finance company, collection agency, or similar institutions. The buyer is still responsible for paying as stated in the disclosure statement even if the member doesn't use Elixir Muscle Recovery's facilities. Whether or not a member utilizes Elixir Muscle Recovery's facilities, ongoing dues or renewal fees must be paid to maintain membership.

Notice to Buyer: Elixir Muscle Recovery acknowledges receipt of the Membership Agreement at the time the buyer signs the Membership Agreement. If a member is under the age of 18, the Buyer must be the member's parent or court-appointed legal guardian. - The holder of this consumer credit Membership Agreement is subject to all claims and defenses that the debtor could assert against the buyer of services obtained pursuant hereto or with proceeds hereof. Unless paid in full, this Membership Agreement constitutes a promissory to pay all debts associated with the membership including past dues and late fees.

Purchased add-ons for a membership can only use the modalities associated with the purchased Primary Membership.

By signing this agreement, you acknowledge and agree to all the terms and conditions of your Elixir Muscle Recovery membership.

Waiver and Release of Liability

Express assumption of risk: I, the undersigned, am aware that there are significant risks involved in all aspects of preventative therapy. These risks include but are not limited to: falls which can result in serious injury or death; injury or death due to negligence on the part of myself, or other people around me; injury or death due to improper use or failure of equipment; strains and sprains. I am aware that any of these above-mentioned risks may result in serious injury or death to myself and or my partner(s). I willingly assume full responsibility for the risks that I am exposing myself to and accept full responsibility for any injury or death that may result from participation in any activity or class while at, or under the direction of an Elixir Muscle Recovery Franchise location. I acknowledge that I have no physical impairments, injuries, or illnesses that will endanger me or others.

CONTRAINDICATIONS

Pneumatic compression is contraindicated for patients with:

•Congestive heart failure

•Deep Vein Thrombosis

•Inflammatory phlebitis or episodes of Pulmonary Embolism

•Infections in the limb, including cellulitis, without appropriate antibiotic coverage.

•Presence of cancer unless for palliative care

•Cold Urticaria

•Cold Erythema

•Cold Hemoglobinuria

•Other indications as identified by the treating physician.

Release

In consideration of the above-mentioned risks and hazards and in consideration of the fact that I am willingly and voluntarily participating in the preventative therapies offered by Elixir Muscle Recovery Centers, I, the undersigned hereby release Elixir Muscle Recovery Centers, their principals, agents, employees, and volunteers from any liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this activity, including those allegedly attributed to the negligent acts or omissions of the above-mentioned parties. This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect. If I am signing on behalf of a minor child, I also give full permission for any person connected with Elixir Muscle Recovery Centers to administer first aid deemed necessary, and in case of serious illness or injury, I permit to call for medical and or surgical care for the child and to transport the child to a medical facility deemed necessary for the well-being of the child.

Parent/Guardian Release Form for Student

Parental Consent for Treatment of Minor I, the parent/guardian of my son or daughter that I'm signing up 18 and under___ hereby authorize and consent to recovery therapies provided by Elixir Muscle Recovery Centers for my child with and without my presence. This authorization shall be valid from the beginning of membership to the termination of the membership date. I do hereby indemnify and hold harmless Elixir Muscle Recovery Centers, its caregivers, staff, or any person involved in providing care to my child who acts in reliance upon this authorization. A child's parent or legal guardian must be contacted to discuss any recovery treatment changes. Please understand that this form is not intended to replace any other forms that the practice may require before treating your child. (Example: Medical director, HIPAA, treatment consents). All other documentation will need to be updated/signed before any treatment is initiated. In the event of a life-threatening emergency, the child may be treated without parental consent. We will do our best to contact the parents or legal guardians. Parent/Legal Guardian agrees by marking the Parental Consent Form Phone number where the parent/guardian can be reached at the time of the appointment:

Indemnification

The participant recognizes that there is risk involved in the types of activities offered by Elixir Muscle Recovery Centers. Therefore, the participant accepts financial responsibility for any injury that the participant may cause either to him/herself or to any other participant due to his/her negligence. Should the above-mentioned parties, or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to reimburse them for such fees and costs. I further agree to indemnify and hold harmless Elixir Muscle Recovery Centers, their principals, agents, employees, and volunteers from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in activities offered by Elixir Muscle Recovery Centers, at the main building or abroad. This includes but is not limited to parks, recreational areas, playgrounds, areas adjacent to the main building, and/or any area selected for the recovery by Elixir Muscle Recovery Franchise Locations.

HIPPA Form

Notice of Privacy Practices 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. This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, or healthcare operations and for other purposes permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition, and related health care services. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. 1. Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office who are involved in your care and treatment to provide health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician's practice. Following are examples of the types of uses and disclosures of your protected health information that your physician's office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time to time to another physician or healthcare provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by assisting with your healthcare diagnosis or treatment to your physician. Payment: Your protected health information will be used and disclosed as needed to obtain payment for your health care services provided by us or another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services, we recommend for you such as: deciding on eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Health Care Operations: We may use or disclose, as needed, your protected health information to support the business activities of your physician's practice. These activities include but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities. We will share your protected health information with third-party "business associates" who perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object. We may use or disclose your protected health information in the following situations without your authorization or by providing you the opportunity to agree or object. These situations include: Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures. Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made to prevent or control disease, injury, or disability. Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws. Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws. Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration for quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects, or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post-marketing surveillance, as required. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) about victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) if a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice's premises) and it is likely that a crime has occurred. Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining the cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye, or tissue donation purposes. Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we 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. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. Workers' Compensation: We may disclose your protected health information as authorized to comply with workers' compensation laws and other similar legally established programs. Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization: Other uses and disclosures of your protected health information will be made only with your written authorization unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization. Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object: We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people who ask for you by name. Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi. Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person who is responsible for the care of your location, general condition, or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care. 2. Your Rights Following is a statement of your rights concerning your protected health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice use for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or the specification of an alternative address or another method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer. You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment, or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions, and limitations. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically. 3. Complaints You may complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint. You may contact your doctor if you have any other questions about privacy practices.

Photography/Video Release

Participants involved in any activities offered by Elixir Muscle Recovery Centers may be photographed or videotaped during training. The undersigned hereby consents to the use of these photographs and/or videos without compensation, on the Elixir Muscle Recovery Centers website, social media platform, or in any editorial, promotional, or advertising material produced and/or published by Elixir Muscle Recovery Centers.

For Opt Out of this section, Email: Info@elixirMuscle.com

If signing for a Minor, The Parent or Guardian (this includes Team Coaches) assumes all responsibility for the Membership Waiver, Dues, and Liability of the Minor.

Signature/Initial

I have read and understood the foregoing assumption of risk and release of liability and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act or omission. I understand that by signing this form I am waiving valuable legal rights.

Also by signing this waiver, I have read and understood all payment terms and conditions of my membership.

Parent Waiver of Release for Minor

Waiver and Release of Liability

Express assumption of risk: I, the undersigned, am aware that there are significant risks involved in all aspects of preventative therapy. These risks include but are not limited to: falls which can result in serious injury or death; injury or death due to negligence on the part of myself, or other people around me; injury or death due to improper use or failure of equipment; strains and sprains. I am aware that any of these above-mentioned risks may result in serious injury or death to myself and or my partner(s). I willingly assume full responsibility for the risks that I am exposing myself to and accept full responsibility for any injury or death that may result from participation in any activity or class while at, or under the direction of Elixir Muscle Recovery Centers. I acknowledge that I have no physical impairments, injuries, or illnesses that will endanger me or others.

Release

Parent/Guardian Release Form for Student

Parental Consent for Treatment of Minor I, the parent/guardian of my son or daughter that I'm signing up 18 and under___ hereby authorize and consent to recovery therapies provided by Elixir Muscle Recovery Centers for my child with and without my presence. This authorization shall be valid from the beginning of membership 06/21/2019 to termination of membership date. I do hereby indemnify and hold harmless Elixir Muscle Recovery Centers, its caregivers, staff, or any person involved in providing care to my child who acts in reliance upon this authorization. A child's parent or legal guardian must be contacted to discuss any recovery treatment changes. Please understand that this form is not intended to replace any other forms that the practice may require before treating your child. (Example: Medical director, HIPAA, treatment consents). All other documentation will need to be updated/signed before any treatment being initiated. In the event of a life-threatening emergency, the child may be treated without parental consent. We will do our best to contact the parents or legal guardians. Parent/Legal Guardian agrees by marking the Parental Consent Form Phone number where the parent/guardian can be reached at the time of the appointment:

Indemnification

HIPPA Form

physician's practice. Following are examples of the types of uses and disclosures of your protected health information that your physician's office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time to time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by assisting with your health care diagnosis or treatment to your physician. Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: deciding of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Health Care Operations: We may use or disclose, as needed, your protected health information to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities. We will share your protected health information with third-party "business associates" that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object. We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include: Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures. Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made to prevent or control disease, injury, or disability. Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws. Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws. Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration for quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects, or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post-marketing surveillance, as required. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) about victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) if a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice's premises) and a crime has likely occurred. Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining the cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye, or tissue donation purposes. Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we 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. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. Workers' Compensation: We may disclose your protected health information as authorized to comply with workers' compensation laws and other similar legally established programs. Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization: Other uses and disclosures of your protected health information will be made only with your written authorization unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization. Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object: We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people who ask for you by name. Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi. Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your location, general condition, or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care. 2. Your Rights Following is a statement of your rights concerning your protected health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice use for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for treatment, payment, or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or the specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer. You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment, or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the

right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions, and limitations. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically. 3. Complaints You may complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint. You may contact your doctor if you have any other questions about privacy practices.

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