Privacy Statement
Effective Date 1/1/16

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.

Verio Healthcare is required by law to maintain the privacy of Protected Health Information (PHI), to
provide individuals with notice of its legal duties and privacy practices with respect to PHI, and to notify
affected individuals following a breach of unsecured PHI.

Verio Healthcare believes that the information we gather about you is of a very private nature and we are
dedicated to keeping this information confidential. The records we create in providing you with care are by
law kept confidential. We are also required to inform you of our policies concerning the use and storage of
your personal health information.

Verio Healthcare maintains the right to update our Privacy Notice. Your personal health information will
always be maintained by our current policies designated in our current Privacy Notice and we must follow
the privacy practices described in this Notice. Verio Healthcare retains the right to change its privacy
practices described in this Notice at any time. A current copy of our Privacy Notice is prominently displayed
in our branch lobby. If you have any comments or questions about our Privacy Notice you may call Angela
Martinez at 888-611-1106 ext. 711.

Privacy Policy

The following describes the manner in which we will use and disclose your personal health information.
Except for the purposes listed below, we will use and disclose your health information only with your written
permission. You may revoke permission at any time by writing to our privacy officer. We also will not
disclose your PHI for marketing purposes, nor will we make any disclosures that constitute a sale of your
PHI. We will disclose health information when required to do so by federal, state or local law.

Services: We may collect and share appropriate information about you to document the medical necessity
of the equipment, supplies or services we are providing. Examples include diagnosis, prescription, referral
and physician or health care provider information.

Payment: We may share appropriate information about you to bill and collect payment for the health care
we provide, including insurance companies and third parties, which includes family members or other
financially responsible parties of which you have informed us. Examples include insurance coverage and
eligibility verification. We may also release appropriate information about you to family or friends that are
helping you with financial responsibilities incurred while receiving equipment, supplies or services from us.

Business operations: We may use and disclose information to monitor and operate our business.
Examples include satisfaction surveys, health care outcomes and utilization reporting, accreditation bodies,
reports provided to any federal, state or local authority (as required by law), or to remind you of equipment,
supplies or service needs.

Legal requirements: We may use and disclose information about you to respond to a court or legal
authoritative body that legally requests information about you. Examples include providing documents for
legal subpoenas or discovery proceedings and having our staff testify about the care and services we have

Workers’ Compensation: We may release health information for workers’ compensation or similar

Business Associates: We may disclose Health Information to our business associates that perform
functions on our behalf or provide us with services if the information is necessary for such functions or
services. For example, we may use another company to perform billing services on our behalf. All of our
business associates are obligated to protect the privacy of your information and are not allowed to use or
disclose any information other than as specified in our contract.

Public health: We may disclose your health information to public health or legal authorities responsible for
preventing or controlling disease, injury or disability.

Data breach notification: We may use or disclose your PHI to provide legally required notices of
unauthorized access to or disclosure of your health information.

Your Rights
Inspect and copy: You have a right to inspect and copy health information that may be used to make
decisions about your care or payment for your care. This includes medical and billing records. To inspect
and copy this health information, you must make your request, in writing, to Angela Martinez. We have up
to 30 days to make your protected health information available to you and we may charge you a
reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may
not charge you a fee if you need the information for a claim for benefits under the Social Security Act or
any other state of federal needs-based benefit program. We may deny your request in certain limited
circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed
healthcare professional who was not directly involved in the denial of your request, and we will comply with
the outcome of the review.

Electronic Copy of Electronic Medical Records: If your PHI is maintained in an electronic format (known as
an electronic medical record or an electronic health record), you have the right to request that an electronic
copy of your record be given to you or transmitted to another individual or entity. We will make every effort
to provide access to your PHI in the form or format you request, if it is readily producible in such form or
format. If the PHI is not readily producible in the form or format you request your record will be provided in
either our standard electronic format or if you do not want this form or format, a readable hard copy form.
We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic
medical record.

Breach notification: You have the right to be notified upon a breach of any of your unsecured PHI.
Amendments: If you feel that Verio Healthcare has incorrect or incomplete information, you may ask us to
amend the information. You have the right to request an amendment for as long as the information is kept
by or for our office. To request an amendment, you must make your request, in writing, to Sean Legaspi.
Accounting of disclosures: You have the right to request a list of certain disclosures we made of health
information for purposes other than services, payment and health care operations or for which you
provided written authorization. To request an accounting of disclosures, you must make your request, in
writing, to Sean Legaspi.

Restrictions: You have the right to request a restriction or limitation on the health information we use or
disclose for treatment, payment, or health care operations. You also have the right to request a limit on the
health information we disclose to someone involved in your care or the payment for your care, like a family
member or friend. For example, you could ask that we not share information about a particular diagnosis
or treatment with your spouse. To request a restriction, you must make your request, in writing, to Sean
Legaspi. We are not required to agree to your request unless you are asking us to restrict the use and
disclosure of your protected health information to a health plan for payment or health care operation
purposes and such information you wish to restrict pertains solely to a health care item or service for which
you have paid us “out-of-pocket” in full. If we agree, we will comply with your request unless the information
is needed to provide you with emergency treatment.

Out-of-Pocket-Payments: If you paid out-of-pocket (or in other words, you have requested that we not bill
your health plan) in full for a specific item or service, you have the right to ask that your protected health
information with respect to that item or service not be disclosed to a health plan for purposes of payment or
health care operations, and we will honor that request.

Confidential Communications: You have the right to request that we communicate with you about medical
matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail
or at work. To request confidential communications, you must make your request, in writing, to Sean
Legaspi. Your request must specify how or where you wish to be contacted. We will accommodate
reasonable requests.

Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you
a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still
entitled to a paper copy of this notice.

If you believe your privacy rights have been violated, you may file a complaint with our office or with the
Secretary of the Department of Health and Human Services. To file a complaint with our office, contact
Sean Legaspi. All complaints must be made in writing. You will not be penalized for filing a complaint.
Complaints may be filed with us at the address below:

Sean Legaspi
30 Fairbanks Ste. 100
Irvine, Ca. 92618