Restorative Touch Inc., LLC dba Elements Massage (Issaquah, WA)

THIS NOTICE DESCRIBES HOW PERSONAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY!

Effective Date: 11/16/2012

OUR COMMITMENT TO YOUR PRIVACY

This Studio, which is a part of the Elements Massage franchise system, understands that medical information about you and your health is personal, and we are committed to protecting that information. This Notice of Privacy Practices for Protected Health Information describes how we and the staff and personnel who provide you with care or services may use and disclose your Protected Health Information (“PHI”) to carry out treatment, payment or healthcare operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI.

PHI is information about you, including demographic information that may identify you, that relates to your past, present, or future physical or mental health or condition and related healthcare services. PHI includes information we create and maintain in the course of providing our past, present, or future health care services to you relating to your physical or mental health or condition or payment for such health care services. Such information may include documentation of your symptoms, examination and test results, diagnoses and treatment protocols. It also may include billing documents for those services.

We may change the terms of this Notice of Privacy Practices at any time. The new notice will be effective for all PHI that we maintain at the time of such change and shall also apply to any subsequently acquired PHI. You may receive any revised Notice of Privacy Practices from the Studio where you receive treatment.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

We may use or disclose your PHI as described in this section. The following are examples of the types of uses and disclosures of your PHI that we are permitted to make without your specific authorization. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our facility. Where state or federal law restricts one of the described uses or disclosures, we will follow the requirements of such state or federal law. Some information, such as certain drug and alcohol information, HIV information, genetic information and mental health information is entitled to special restrictions related to its use and disclosure.

The following are general descriptions only. They do not cover every example of disclosure within a category. However, all of the ways we are permitted to use and disclose your PHI will fall within one of the categories in this Notice of Privacy Practices.

1. Treatment

   We may use PHI about you to provide you with medical treatment or services.

   We may disclose medical information about you to massage therapists, doctors, nurses, technicians, medical or massage therapy students, or other personnel who are involved in your care. For example, we may consult with a doctor to determine if an orthopedic injury may be involved in your condition and that doctor may need to know your medical history and/or what medications you are taking. Our disclosure of PHI may be done electronically to expedite the coordination of services to you.

2. Payment

   Your PHI will be used as needed to obtain payment for your healthcare services. This may include, for example, disclosures to health insurance plans for the purpose of making determinations regarding insurance coverage and your eligibility for insurance benefits. Other examples may include disclosures to allow third parties, including insurance plans, to review the services provided to you for medical necessity and for undertaking utilization review activities. We may submit requests for payment to your health insurance company and respond to health insurance company requests for information about the services we provided to you. Obtaining insurance approval for covered services at the Studio may require that your relevant PHI be disclosed to your health plan.

3. Healthcare Operations

   We may use or disclose your PHI as needed to support our business activities.

   These activities include, but are not limited to, quality assessment activities, employee/staff review activities, training students, licensing, and conducting or arranging for other healthcare operations. We may contact you about alternative treatment options for you or about other benefits or services we provide. We may also use and disclose your PHI to an outside company that performs services for us such as accreditation, legal, computer, or auditing services. These outside companies are called “business associates” and are required by law to keep your PHI confidential.

4. Appointment Reminders

   We may contact you by phone at any telephone number you provide to us to remind you that you have an appointment with us.

5. Individuals Involved in Your Care or Payment for Your Care

   We may release medical information to anyone involved in your medical care,

   e.g. a friend, family member, personal representative, or any individual you identify. We may also give information to someone who helps pay for your care. We may also tell your family or friends about your general condition.

6. Disaster Relief Efforts

   We may use or disclose your PHI to an authorized public or private entity assisting in disaster relief efforts so that others can be notified about your status, condition, and location.

7. Research

   We may disclose your PHI to researchers, subject to the confidentiality provisions of state and federal law. Such research projects must be approved through a special review process to protect patient safety, welfare, and confidentiality.

8. Required By Law

   We may use or disclose your PHI to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.

9. To Prevent a Serious Threat to Health or Safety

   We may use and disclose PHI when necessary to prevent or lessen a serious and imminent threat to your health and safety or the health and safety of the public or another person. Such disclosure would be to someone able to help stop or reduce the threat.

10. Organ and Tissue Donation

    If you are an organ donor, we may release your PHI to organizations that obtain, bank or transplant organs, eyes, or tissue, as necessary to facilitate organ or tissue donation and transplantation.

11. Military and Veterans

    When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel: (i) for activities deemed necessary by appropriate military command authorities as authorized or required by law; (ii) for the purpose of obtaining a determination by the Department of Veteran Affairs of your eligibility for benefits; or (iii) to foreign military authority if you are a member of such authority’s military services.

12. National Security and Intelligence Activities

    As required by law, we may disclose your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities.

13. Workers’ Compensation

    We may use or disclose PHI for Workers’ Compensation or similar programs as authorized or required by law. These programs provide benefits for work-related injuries or illnesses.

14. Public Health Disclosures

    We may disclose your PHI for public health activities such as:

    1. preventing or controlling disease (such as cancer or tuberculosis), injury or disability;

       medications, or defects or problems with products;

       1. notifying persons of recalls, repairs, or replacements of products they may be using;

       2. notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition.

15. Abuse and Neglect Reporting

    We may disclose your PHI to a public health authority that is authorized by law to receive reports of abuse, neglect or domestic violence.

16. Health Oversight

    We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the healthcare system, government benefit programs, other government regulatory programs and civil rights laws.

17. Lawsuits and Legal Proceedings

    We may disclose PHI to courts, attorneys and court employees in the course of conservatorship, writs, and certain other judicial or administrative proceedings. We may also disclose PHI about you in response to a court or administrative order, or in response to a subpoena, discovery request, warrant or other lawful process.

18. Law Enforcement

    As authorized or required by law, we may release PHI:

    1. To identify or locate a suspect, fugitive, material witness, certain escapees, or missing person(s);

    2. About a suspected victim of crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;

       a crime or crime victims; or the identity, description or location of the person(s) who committed the crime.

19. Coroners, Funeral Directors and Organ Donation

    We may disclose PHI to a coroner, funeral director or medical examiner as necessary to permit them to carry out their duties. This may be necessary, for example, to identify a deceased person.

20. Protective Services for the President and Others

    As required by law, we may disclose PHI to authorized federal officials so they may conduct special investigations or provide protection to the President, other authorized persons or foreign heads of state.

21. Required Uses and Disclosures

    Under the law, we must make disclosures to you and to the U.S. Department of Health and Human Services when required to determine our compliance with the requirements of the Federal Privacy Standards.

22. Marketing or Sale of Health Information

Most uses and disclosures of PHI for marketing purposes or any sale of your PHI would require your written authorization.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION

Other uses and disclosures of your PHI not covered by this Notice will be made only with your written authorization. If you authorize us to use or disclose your PHI, you may revoke, in writing, your authorization at any time, but your revocation will only be effective for future uses and disclosures and will not affect any use or disclosure made in reliance on your authorization and before your revocation. If you are not present or able to authorize or object to the use or disclosure of PHI, we, as your care provider may, using professional judgment, determine whether the disclosure is in your best interest.

In such event, only the PHI that is relevant to your healthcare will be disclosed.

YOUR RIGHTS REGARDING YOUR PHI

The PHI that we collect and maintain about you is the property of this Studio.

Set forth below is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights. We have the right to deny your request in certain circumstances. We will inform you if your request is denied.

1. Right to Access Your PHI. You may inspect and obtain a copy of your PHI that is contained in a designated record set for as long we maintain the PHI. A “designated record set” contains medical and billing records and any other records that your care provider uses for making decisions about you. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding; and, PHI that is subject to law and prohibits access to PHI. Depending on the circumstances, a decision to deny access may be reviewable. If the information you request is maintained electronically, and you request an electronic copy, we will provide a copy in the electronic form and format you request if the information can be readily produced in that form and format. If the information cannot be readily produced in that form and format, we will work with you to come to an agreement on form and format.

   Please contact this Studio if you have questions about access to your PHI. If you request a copy of the information, we may charge a fee for the costs of retrieving, copying, mailing, and supplies associated with your request. Your records remain the property of this Studio.

2. Right to Request Amendment of PHI. If you believe that PHI we have about you is incorrect or incomplete, you may ask us to amend the information or add an addendum (addition to the record). You have the right to request an amendment or addendum for as long as the information is kept by this Studio. To request an amendment, your request must be made in writing and submitted to the attention of the Privacy Officer at the Studio where you receive treatment. You must be specific about the information you believe to be incorrect or incomplete and you must provide a reason to support the request. We may deny your request if it is not in writing, we cannot determine the information you are asking to be changed or corrected, or your request does not include a reason to support the change or addition. In addition, we may deny your request if you ask us to amend information that: (i) was not created by this Studio;

   (ii) is not part of the PHI kept by this Studio; (iii) is not part of the information that you would be permitted to inspect and copy; or (iv) we believe to be accurate and complete.

3. Right to Request Addendum. To request an addendum, the addendum must be in writing and submitted to the attention of the Privacy Officer at the Studio where you receive treatment. An addendum must not be longer than 250 words per each alleged incomplete or incorrect item in your record.

4. Right to Request an Accounting of Certain Disclosures. You may request a list of our disclosures of your PHI, subject to certain and limitations. To request an accounting of disclosures, you must submit your request in writing to the Studio’s Privacy Officer. Your request must state a time period that may not be longer than six years prior to the request date. You are entitled to one accounting within any 12 month period at no cost. For additional lists during the same 12 month period, we

   may charge you for the cost of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at any time before any costs are incurred.

5. Right to Restrict Use or Disclosure of Your PHI. You may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care, the payment for your care, or for notification purposes as described in this Notice.

   To request a restriction, you must make your request in writing to the Privacy Officer at the Studio where you receive treatment. In your request, you must tell us: (i) what information you want to limit; (ii) whether you want to limit our use, disclosure or both; and (iii) to whom you want the limits to apply.

   Except as provided in the following paragraph, we are not required to agree to your request. If we do agree, our agreement must be in writing, and we will comply with your request unless the information is needed to provide you emergency care.

   However, if we do agree to the request, we will honor the restriction until you revoke it in writing or we notify you.

   We are required to agree to a request not to share your information with your health plan if the following conditions are met: (i) we are not otherwise required by law to share that information; (ii) the information would be shared with your insurance company for payment purposes; and (iii) you pay the entire amount due for the health care item or service out of your own pocket or someone else pays the entire amount for you.

6. Right to Request Confidential Communications From Us. You have the right to request that we communicate with you about health care matters in a certain way or at a certain location. For example, you may request that we contact you only at home or only by mail. We will attempt to accommodate reasonable requests. We will not request an explanation from you as to the basis of the request. Please make this request in writing to the Studio’s Medical Records Department.

7. Right to Be Notified of a Breach. You have a right to be notified in the event that we discover a breach of unsecured PHI, as defined under federal law.

8. Right to Obtain a Paper Copy of This Notice. You have the right to obtain a paper copy of this notice, even if you agreed to receive such notice electronically. You may ask us to give you a copy of this notice at any time. To request a copy of this notice, you can make your request in writing addressed to the Privacy Officer at the Studio where you receive treatment.

CHANGES TO PRIVACY PRACTICES AND THIS NOTICE

We reserve our right to change our privacy practices and this Notice. We reserve the right to make the revised or changed Notice effective for PHI we already possess, as well as any information we receive in the future. We will post a copy of the current Notice in the Studio. In addition, at any time you may request a copy of the current Notice in effect.

QUESTIONS AND COMPLAINTS

You may file a complaint with us or with the Secretary of the Department of Health and Human Services if you believe we have violated your privacy rights. You may file a complaint with us by notifying the Studio’s Privacy Officer. We will not retaliate against you for filing a complaint. For further information about the complaint process, or to make any requests or inquiries, you may contact the Studio’s Privacy Officer at:

Attention: Privacy Officer Elements Massage

39 E. 4th Ave

San Mateo, CA 94401 Phone: 650.558.8775

Fax: 650.558.8745

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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