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.

Effective Date: 12/01/2025

OUR LEGAL DUTY

We are required by law to maintain the privacy and security of your protected health information (“PHI”). We are also required to provide you with this Notice of Privacy Practices and to follow the terms of this Notice.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

1. For Treatment

We may use and disclose your health information to provide, coordinate, or manage your healthcare and related services.
Example: Sharing information with laboratories, pharmacies, or other healthcare providers involved in your care.

2. For Payment

We may use and disclose your health information for billing, payment collection, eligibility determination, and related activities.
Example: Submitting claims or collecting payment for services rendered.

3. For Healthcare Operations

We may use and disclose your information for clinic operations such as quality assessment, staff training, licensing, auditing, legal services, and business management.

OTHER PERMITTED USES AND DISCLOSURES

We may also use or disclose your information:

• As required by law

• For public health activities

• To report abuse, neglect, or domestic violence

• For health oversight activities

• For judicial or administrative proceedings

• For law enforcement purposes

• To avert a serious threat to health or safety

• For workers’ compensation claims

• To coroners, medical examiners, or funeral directors

• For organ donation

• For research (with required approvals)

• To military authorities or national security agencies, when required

USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION

We will not use or disclose your health information for the following purposes without your written authorization:

• Marketing purposes

• Sale of your health information

You may revoke an authorization at any time in writing.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the right to:

1. Get a Copy of Your Records

You may request to inspect or obtain a copy of your health information. We will provide it within the time required by law.

2. Request a Correction

You may request an amendment if you believe your information is incorrect or incomplete.

3. Request Confidential Communications

You may request to be contacted in a specific way (e.g., phone, email, mail) or at a specific location.

4. Request Restrictions

You may ask us not to use or disclose certain information. We are not required to agree, except for certain self-paid services.

5. Receive an Accounting of Disclosures

You may request a list of certain disclosures we have made of your health information.

6. Get a Copy of This Notice

You may request a paper copy of this Notice at any time, even if you agreed to receive it electronically.

7. File a Complaint

If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint.

BREACH NOTIFICATION

We will notify you if a breach occurs that compromises the privacy or security of your unsecured protected health information.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice at any time. Changes will apply to all health information we maintain. The revised Notice will be available in our office and on our website, if applicable.

CONTACT INFORMATION

If you have questions, concerns, or wish to exercise your rights, contact:

Privacy Officer: Lesa May
Clinic Name: Peak Performance Health & Wellness
Address: 109 Lou Ann Dr., Herrin, IL 62948
Phone: 618-727-5532
Email: office@peakperformancehw.com

COMPLAINTS TO HHS

You may also file a complaint with:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-877-696-6775
www.hhs.gov/ocr

ACKNOWLEDGMENT OF RECEIPT

You may be asked to sign a separate acknowledgment confirming that you received this Notice of Privacy Practices.