Electronic 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.

Dear Patient: Popov Psychiatry PLLC dba Monarch Concierge, a Nevada professional limited liability company (“we”, “us”, “our”, “Practice”), understands that patient (“you”, “your”) privacy is important. This Notice of Privacy Practices (“Notice”) applies to Practice and each of our Business Associates, as applicable.

Protected health information/PHI

Protected health information (“PHI”) relates to information about you and your health, which could be used to identify you. Each time that you visit us, we create a medical record of your PHI and services that you receive.

Our obligations regarding your PHI

We recognize that information about you and your health is confidential, and we are committed to protecting this information. This Notice applies to all your health records that we create. We are required by law to preserve the privacy and security of your PHI. While there is no absolute guarantee of privacy, we are committed to protecting your privacy. We have established reasonable and appropriate measures to protect your PHI against unauthorized uses and disclosures. Federal law mandates that we share this Notice with you, and that we make a good faith effort to obtain a signed document acknowledging your receipt of this Notice. We are also required to follow the terms of this Notice. In the event that we are involved in a breach of your PHI, we will immediately notify you.

This Notice’s effective date and potential changes

The effective date (“Effective Date”) shall be the date of receipt of this Notice, and it applies to health records that we create for you. We reserve the right to change this Notice after the Effective Date. We can change the terms of this Notice, and the changes will apply to all the information we have about you. The new Notice will be available upon request.

How we may disclose your PHI

The laws of the state where Practice is located, and federal laws, allow disclosures of your PHI in some cases. Some of these disclosures do not require your verbal or written permission. The following information describes how we may share your PHI. We may typically use or share your PHI in these ways:

When we treat you We can use your PHI and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.

As we operate/manage our practice organization We can use and share your PHI to operate and manage our practice, improve your care, and contact you when necessary. Example: We use your PHI to manage your treatment and deliver healthcare services.

When we bill for healthcare services We can use and share your PHI to bill and obtain payment from health plans or other entities or from you. Example: We give information about you to your health insurance plan so it will pay for your services.

When we help with public health and safety issues We can share your PHI for certain situations such as: Preventing disease; Helping with product recalls; Reporting adverse reactions to medications; Reporting suspected abuse, neglect, or domestic violence; and Preventing or reducing a serious threat to anyone’s health or safety.

When we perform research We can use or share your PHI for health research.

To comply with the law We will share your PHI if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

When we respond to organ and tissue donation requests We can share your PHI with organ procurement organizations.

When we coordinate on end of life care and related decisions We can work with a medical examiner or funeral director regarding your PHI shared. We can share your PHI with a coroner, medical examiner, or funeral director at end of life.

To address other government requests We can use or share your PHI: For workers’ compensation claims; For law enforcement purposes or with a law enforcement official; With health oversight agencies for activities authorized by law; and for special government functions such as military, national security, and presidential protective services.

To respond to lawsuits and legal actions We can share your PHI in response to a court or administrative order, or in response to a subpoena.

How else can we use or share your PHI?

We are allowed or required to share your PHI in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. We have not listed every use and disclosure in this Notice. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

We can use and disclose your PHI in certain situations with your verbal or written agreement For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care; Share information in a disaster relief situation; and Include your information in a hospital directory. If you cannot tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to your health or safety.

We can use and disclose your PHI in certain situations requiring your written permission If there are situations that have not been described above, we will obtain your written permission. In these cases, we never share your PHI unless you give us written permission: Marketing purposes; Sale of your information; and Most sharing of psychotherapy notes. With fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again. If you provide us with written permission, you may change your mind at any time. Please let us know in writing if you change your mind.

Your rights regarding your PHI

You have the following rights regarding your PHI that is created in our Practice. This section explains some of your rights and our responsibilities to assist you.

You may request an electronic or paper copy of your PHI medical record

You can ask to see or receive an electronic or paper copy of your medical record and other PHI that we have about you. Ask us how to do this. We will provide a copy or a summary of your PHI, usually within thirty (30) days of your request. We may charge a reasonable cost-based fee.

Ask us to correct your PHI medical record You can ask us to correct PHI about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we will tell you why in writing within sixty (60) days.

Request confidential communications You can ask us to contact you in a specific way (for example, home or office phone), or to send mail to a different address. We will say “yes” to all reasonable requests.

Ask us to limit what PHI we use or share You can ask us not to use or share certain PHI in connection some of our services, but… We are not required to agree to your request, and we may say “no” if we believe that would affect your care. Because you are privately paying for some medical or health services, you may ask us to refrain from sharing PHI related to those private pay services with your health insurance plan. We will respect that request unless we are legally obligated otherwise under applicable laws.

You may request a list of who we have shared information You can ask for a list (accounting) of the times we have shared your PHI for six (6) years prior to the date you ask, who we shared it with, and why. We will provide one accounting of PHI disclosures for you per year for no charge, but we can charge a reasonable, cost-based fee if you ask for another PHI disclosure accounting within the same year. The accounting will only contain PHI disclosures required to be reported by law. Example: PHI disclosures regarding your treatment are not required by law to be reported and will not be in your accounting.

Get a copy of this Notice You can ask for a paper copy of this Notice at any time, even if you have agreed to receive this notice electronically. We will provide you with a Notice paper copy promptly.

Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

We will make sure the person has this authority and can act for you before we take any action.

Ask questions or file a complaint if you believe your rights are violated

If you have questions about this Notice or you believe that your rights are being violated, please contact us immediately:

Practice contact information:

Monarch Concierge
Attention: Dr. Michael Popov
9360 W Flamingo Rd Ste 110-326, Las Vegas NV 89147
drpopov@monarch-concierge.com

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints. Please provide as much information as possible so that the Department of Health and Human Services can thoroughly investigate your concern or complaint. We will not retaliate against you for filing a complaint with us, or the Department of Health and Human Services.

Thank you,

Monarch Concierge

Acknowledgment of Receipt of Notice of Privacy Practices

Popov Psychiatry PLLC dba Monarch Concierge, a Nevada professional limited liability company, is required to provide Patient with a copy of Practice’s Notice of Privacy Practices (“Notice”) that states how Practice may use and/or disclose Patient’s health information. Please sign this form to acknowledge receipt of the Notice.