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.

If you have questions about this notice or want more information, please contact our Privacy Officer. The effective date of this notice is March 25, 2024.

Iron Horse Men's Health needs to collect information from you to provide appropriate treatment and receive payment for services. Although we are not a "covered entity" under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), we adhere to Colorado law in limiting the use and disclosure of your information.

We may use and disclose your health information for treatment, payment, and healthcare operations.

Treatment: We may use and disclose your information to provide you with medical treatment and services. Your information may be shared with individuals and facilities involved in your care to coordinate and provide services such as prescriptions, lab tests, meals, and x-rays.

Payment: We may use and disclose your information to receive payment for services and treatment provided to you. Your information is used to create a bill and may be disclosed when we send the bill to your insurance company, you, or a third party. The payer may request more information to determine coverage.

Healthcare Operations: We may use and disclose your information for healthcare operation purposes, such as quality assessment, educational purposes, business planning, and compliance.

Appointment Reminders: We may send you appointment reminders. You can request these reminders be sent to a confidential or alternative address.

Treatment Alternatives: We may inform you about treatment alternatives and other health-related benefits and services.

Waiting Rooms: We may use a sign-in sheet at the registration desk and call you by name in the waiting room when ready for your treatment.

We may also disclose your health information without your consent or authorization in certain circumstances, such as:

When required by law (e.g., reporting gunshot wounds to the police)For public health purposes (e.g., reporting communicable diseases)To prevent a serious threat to health or safetyFor research approved by a privacy board or institutional review boardFor health oversight activities (e.g., investigations, audits, licensing)In judicial and administrative proceedingsFor law enforcement activitiesTo identify a deceased individual or determine the cause of deathFor military and veterans affairsTo correctional institutions or law enforcement officials if you are an inmateFor organ and tissue donationFor workers' compensationFor specialized governmental functions (e.g., national security)To business associates who assist us in our operations, with assurances of confidentialityTo friends, relatives, and other caretakers involved in your careFor disaster relief purposes

Except as provided above, we will obtain your written authorization before disclosing your information for other purposes. This includes disclosures for psychotherapy notes, marketing, and the sale of information. You have the right to revoke any authorization at any time.

Your Rights:

You have the right to request restrictions on the use and disclosure of your information. You have the right to request communications be made at an alternative address or phone number.You have the right to inspect and copy your medical record.You have the right to request amendments to your medical record if you believe it is incorrect or incomplete.You have the right to request a list of disclosures of your health information for reasons other than treatment, payment, or healthcare operations.You have the right to request a paper copy of this Notice.

Our Duties:

We are required by law to maintain the privacy of your information and provide you with this Notice.

We are required to notify you if there is a breach of your unsecured information.We are required to adhere to the terms of the current Notice.We may change the terms of this Notice, and the revised Notice will apply to all health information in our possession. You can request a copy of the revised Notice from our Privacy Officer at the number listed at the beginning of this form.