HIPAA Privacy Practices Acknowledgment

StayWell Health PC

State of Incorporation: California

Notice of Privacy Practices.

StayWell Health PC (“Practice”) is required by federal law, including the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), to maintain the privacy of your protected health information (“PHI”). Our Notice of Privacy Practices (“Notice”) explains in detail:

• How we may use and disclose your PHI for treatment, payment, and healthcare operations.

• Your rights regarding access, amendment, restriction, and accounting of disclosures of your PHI.

• Our duties to safeguard your information and notify you in case of a breach.

The full Notice is available on our website and can be provided in print upon request.

Limits of Liability.

• Independent Contractors: All telemedicine services are provided by independent contractor physicians and physician groups. Each Provider is individually responsible for safeguarding PHI they create or maintain.

• No Guarantee of Security Beyond HIPAA: While Practice complies with HIPAA and applicable state laws, no technology system is 100% secure. By consenting, you acknowledge the risks inherent in electronic transmission of PHI.

Patient Rights Under HIPAA.

You have the right to:

• Inspect and obtain a copy of your medical record.

• Request corrections to your PHI if you believe it is inaccurate.

• Receive an accounting of disclosures of your PHI.

• Request restrictions on the use or disclosure of your PHI (Practice is not required to agree to all requests).

• Request confidential communications in an alternative manner (e.g., mailed to a different address).

• File a complaint with Practice or directly with the U.S. Department of Health and Human Services if you believe your privacy rights have been violated.

Communications and Technology.

Telehealth visits will only occur on secure, encrypted platforms approved by Practice. PHI will never be communicated through text messaging, social media, or unencrypted email. Artificial intelligence scribing technology may be used to assist Providers in creating accurate medical records. All such systems are subject to HIPAA compliance.

Duration of Acknowledgment.

This Acknowledgment remains valid for one year from the date signed, unless revoked in writing.

Acknowledgment of Receipt.

By signing this Acknowledgment, you confirm that:

• You have been provided access to the Practice’s Notice of Privacy Practices.

• You understand that Practice may use and disclose your PHI as described in the Notice.

• You are aware you have the right to request restrictions, request confidential communications, and receive a copy of this Acknowledgment.