Notice of Privacy Practices of Sesi Signature Inc.

This notice describes how your medical records and related personal information may be used and disclosed by Sesi Signature Inc. and how you are able to access this information. Please review it carefully. This consent form applies to all providers and all locations that I may receive care at through Sesi Signature Inc.

Sesi Signature Inc., is required by law to maintain the privacy of your protected health information (PHI). This document provides you with notice of your privacy rights and the legal duties and privacy practices of your practitioners and Sesi Signature Inc. with respect to your PHI. All terms of this notice regarding your PHI will be followed, unless terms are amended or added, to remain in accordance with federal and state law. If this notice changes, you will receive a copy of the revised notice via U.S. mail, to the last address you have provided for this communication purpose, or via email if you have indicated you prefer to receive electronic communication. At any time, you may request a paper copy of this notice, or an amended version, and one will be provided to you.

Understanding Your Protected Health Information:

Protected health information is any identifiable patient information that contains:

Any information that concerns your health and medical status or personal identifying information;
Any information about medical or psychiatric care that has been, is being, or will be delivered to you;
Financial information regarding payment for your medical visits and procedures and insurance information; and
Any information about genetic testing, results, or information about you or your family members; a request for genetic services; clinical research participation that is related to genetics; or symptoms and/or diagnosis of a genetic disease or condition of either you or your family member(s).

The purpose of creating and storing your medical record is to document your hospital and clinic visits and communications between you and your health care providers. This process allows Sesi Signature Inc. to provide informed and quality care to our patients and to remain in compliance with all applicable federal and state laws. Your medical record will contain, among other things, examinations and test or lab results, diagnoses, treatments, visit notes, prescription orders, and a plan for future care or treatment.

Your Health Information Rights

Although your health record is the physical property of Sesi Signature Inc., the information contained in it belongs to you. You have the following privacy rights:

The right to request restrictions on the use and disclosure of your PHI to carry out treatment, payment, or health care operations.

-It is important for you to know that if agreeing to certain requests would negatively affect your care, Sesi Signature Physician Assistant Corp. reserves the right to deny your request.

-If you pay out-of-pocket, in full, for a health care or service cost, you may request Sesi Signature Inc.. to not share that information or the information related to your service with your health insurer, and Sesi Signature Inc.. will abide, provided there is not a law that requires that information to be shared.

The right to ask Sesi Signature Inc. to correct health information that you believe to be incorrect or incomplete. Please ask us how to do this. Sesi Signature reserves the right to deny your request, and you will be given notice in writing within 60 days as to why the request was denied. Additionally, if your request is denied, you can speak with your health care provider and request documentation of your request to be included in your health record, along with the denial, and for those documents to be included in any future disclosures of your PHI. Your request for amendment will automatically be denied if the documentation was created by an outside agency.
The right to ask us to contact you confidentially. You may specify to us the means in which you would prefer communications (via telephone, U.S. mail, email, etc.), and Sesi Signature Inc.. will do its best to accommodate this request, within reason.

The right to request restrictions on the use and disclosure of your name, location of where you receive treatment or care, your health or medical status, diagnoses, or any other identifying information. You have the right to limit:

Disclosures to your family and friends; certain disclosures to those involved in your care, unless it would negatively affect the quality of the care you would receive; or in the event of a disaster relief situation.
The right to get a list (an “accounting”) of those with whom we’ve shared your health information and why. This information is available to you for up to six years prior to the date you request this list. Not included in this list is:
Disclosures you requested Sesi Signature to make to specific individuals or entities.
Disclosures done for purposes of payment.
Disclosures that are industry practice for health care operations.
Disclosures that are mandatory according to federal and state law or for the purposes of maintaining our license with DHS or the Department of Health.

One accounting will be available to you per year at no cost. If you require more than one list in a 12 month span, you may be required to pay a reasonable fee for it.

The right to file a complaint if you feel your rights have been violated and Sesi Signature will not retaliate against you if you file a claim.

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/.
The right to inspect and copy your PHI, in the presence of a Sesi Signature Inc. staff person, unless in the case of psychotherapy notes, if your clinician or treatment team has determined that disclosure to you of the information contained would be detrimental to your physical or mental health, or it is likely to cause you to inflict self-harm or harm to another.

You may request copies of your PHI by submitting a written request or filling out a release of information form that details your request. Sesi Signature Inc.. will provide requested documents within a reasonable period, no more than 10 business days. There may be a fee for each page copied.

The right to rescind a release of information or authorization to release your PHI to an outside entity or agency. If the information has already been shared with your permission, we cannot take the information back, however, if you have given permission and change your mind, you can rescind the release of information at any time. You may do this by submitting your request in writing.

Sesi Signature Inc. Responsibilities regarding your PHI:

It is our duty to keep your health information secure, private, and protected.
It is our duty to notify you if there has been a breach of your health information.
We will follow the responsibilities and practices laid out in this notice and remain up to date with changes in federal or state law to remain in compliance.
We will abide by your requests regarding your PHI, within reason, and according to applicable federal and state law.
We will never share your information without written consent from you for marketing purposes or sale of your information.
We will make all attempts to ensure your PHI is a thorough and complete representation of the services and treatments you receive with Sesi Signature Inc.

How Sesi Signature Inc.. may use or disclose your PHI, with your consent (please note that releases of information or written consent that is signed and dated is generally only valid for a period of one year, or less if specified):

For the purposes of your treatment, payment for services, and the general operations of Sesi Signature.
When you have requested your medical record, or portions of your medical record, be released to another agency/entity.
When organ and tissue donation or organ procurement organizations request it.
For health, medical, or scientific research, provided you do not object to it. If you object, your health information will not be released.

If you do not object and portions of your health record are released, you may request, and we will provide, information on to whom the health record was released to and the date it was released.

In most cases, Sesi Signature Inc. will not connect your name to health records released for research purposes.

Sesi Signature Inc. may share your personal information with public health or other authorized agencies without your consent (under federal and state law) when:

The disclosure is to a related entity that is affiliated with Sesi Signature Inc. and it is related to your treatment.
The disclosure is to provide health care services in the event of a medical emergency or disaster relief situation.
There is a substantial barrier to communicating with you and Sesi Signature Inc. medical or clinical staff believe you intend for us to provide care to you.
Health care services are provided to you as an inmate.
Sesi Signature is required by law to treat you and we are unable to obtain your consent, despite attempting to do so.
Sesi Signature is complying with certain government functions such as military, national security, correctional facilities, and presidential protective services.
It is necessary to protect or reduce a serious threat to someone’s health or safety. You will be informed of this disclosure, unless informing you would further put that person’s safety or health at risk.
Suspected abuse or neglect of a child or vulnerable adult is reported.
Reporting product recalls.
Preventing or controlling diseases.
Reporting adverse reactions to medications.
It is a part of Sesi Signature Inc. oversight activities, such as audits, inspections, or investigations from a government agency.
It is a part of managing our operations, such as with business partners that we do work with but are not our employees or affiliates. These business partners are required by law to keep your information secure and protected.
It is required for workers’ compensation claims.
It is necessary to work with a medical examiner or coroner.
A public health authority is collecting information regarding vital life events, such as birth or death.
Legal actions require it, such as a court order, grand jury subpoena, warrant, or other legal process or for law enforcement purposes.
To defend Sesi Signature Inc. in a legal action or related proceedings you bring against Sesi Signature Inc.
Federal or state law requires it.

Special Provisions for PHI Related to Psychotherapy Notes or Substance Use Treatment:

Psychotherapy notes and records related to substance use treatment may be a part of your PHI. These portions of your health record require separate written consent that explicitly states the types of records that will be released or communication that can take place, the purpose of the release, the expiration date, and the person, agency, or entity the records are to be released to.

Mandated Reporting

Under certain State Law, persons in designated professional occupations are mandated to report suspected child abuse or neglect of vulnerable adults. Persons who work with children and families are in a position to help protect children and vulnerable adults from harm. These persons may be required by law to report to authorities if they know or have a reason to believe that a person is being abused or neglected, and this may be done without your consent. Behavioral health personnel may be required to break confidentiality and report certain information to the appropriate authorities.

Medical Power of Attorneys/Durable Power of Attorneys.

If you have a health care directive and have appointed a medical power of attorney or a durable power of attorney, this appointed person will have the ability to make medical decisions for you and access your PHI, but only in the case that you become incapacitated or incompetent.

Adults who Have Guardians:

If a guardian has been appointed to you through a court order, your guardian has the power to give necessary consent for you to receive medical or professional care and your guardian also has full access to your PHI.

Minors:

Minors are persons who are under the age of 18. Parents of certain minor children, who are able to consent for treatment on their own without their parent’s involvement, do not have access to their minor child’s health record and the release of records or PHI will require written consent from the minor child. The only exception to this is if the health care professional treating the minor believes that failure to inform the minor’s parent or guardian would seriously jeopardize the health of the minor patient. Minors who are able to consent for treatment on their own include:

Minors who live apart or separately from their parents or legal guardians and is managing his or her own financial affairs.
Minors who are married.
Minors who are parents to a biological child.
When the services are to determine the presence of or to treat pregnancy and conditions associated therewith.
When the services are related to venereal disease(s)/STDs/STIs.
For Hepatitis B vaccinations.
When the services are for the assessment or treatment of alcohol or drug abuse.
Emergency treatment for medical, dental, or other health services if the risk to the minor’s life or health is of such a nature that treatment should be given without delay and the requirement of consent would cause a delay in treatment.

Additionally, parents may be deemed to not be personal representatives of their minor child, and therefore have limited or no access to their minor child’s PHI if the minor is subject to domestic violence, abuse, neglect, or endangerment and notifying the parent of the minor’s PHI may place the minor in further danger.

Cell Phone, Cameras, or Other Recording Devices

It is our duty and responsibility to ensure that your PHI is kept secure and protected; therefore,

we prohibit any type of recording or photographs while you are receiving services. Some

providers may require additional protection that may necessitate you to surrender your mobile

device, or any other type of recording or photography device, while you are actively receiving

services. Health care providers may also take action and potentially discharge you from services

if confidentiality rules are not abided by in regard to photography or recording.

For information or concerns related to Privacy Practices, please contact Sesi Signature

Health at:

+1 (949)695-8478

Contact@SesiSignature.com

Mail: 2082 Michelson Drive Suite 100, Irvine, California 92612

Consent for Treatment:

I acknowledge and understand that I have sought out treatment for a physical or behavioral

health condition and that I consent to Sesi Signature Health and its providers providing care for

me. The care may include, but is not limited to: management of symptoms, diagnosis, testing,

therapy, education, prescriptions, and other various types of treatment. In order to effectively

provide me care, I understand that information may need to be gathered, and that this will

become a part of my health record with Sesi Signature Health.

I also understand that I may refuse treatment, or certain types of treatment, at any time, however,

refusal may negatively affect my overall outcome of treatment. In health care, there are no

guarantees for specific outcomes.

Health Records and Personal Health Information (PHI):

I acknowledge that if there is a particular request I have regarding my PHI, I will make this

known to my provider or providers and that they will do their best, within reason, to honor my

request.

I also acknowledge that in order for Sesi Signature Health to release my records or PHI, upon my

request, to another person, agency, or entity, it will require me to sign a release of information,

that cannot be consented to orally.

If at any time I decide I want to revoke a release of information, I must do so in writing.

Page 6 of 8Communication

I understand that Sesi Signature Health may need to contact me to discuss services I have

received, financial matters related to billing, and for future appointments, or new services. I

consent that Sesi Signature Health may contact me (please check the box of which forms of

communication you consent to and fill in the contact information):

□ Email:

________________________________________________________

□ Home Phone:

__________________________________________________

□ Cell Phone:

____________________________________________________

□ Home Address:

_________________________________________________

______________________________________________________________

Can staff leave a message on your phone regarding upcoming appointments?

□ Yes

□ No

Health Records for Research Purposes

Medical research is a fundamental way for health care and health care treatments to evolve and

improve. My health records, if I consent, will always be handled according to all applicable

federal and state privacy laws, and many times, my name will not be connected to the

information released from my health record.

□ I have checked this box because I do not consent to my health records to be used for

research purposes.

Consent to Communicate with Insurance

I acknowledge and understand that Sesi Signature Health will need to release my PHI for

purposes of billing, claims, and payment for the services I receive.

I also acknowledge that it is my responsibility to submit all insurance information to Sesi

Signature Health and to contact my insurance company to inquire about coverage for the

providers I may see and the services I may receive.

Page 7 of 8

Privacy Practices Notice and Client Consent Form

By signing this form, I acknowledge that I have been given an opportunity to review the Privacy

Practices and Client Consent, have received a copy if I requested one, that I understand the

information presented, and I agree to the provisions contained in this form. If I have questions or

concerns, I will speak to my provider or an appointed person with Sesi Signature Health. I

understand that this form is valid until revoked by me in writing.

Signature of Patient/Client or Legal Representative Date:

__________________________________________ ___________

Relationship to Patient/Client (if applicable)

________________________________________________