HIPAA NOTICE OF PRIVACY PRACTICES

(Effective August 1, 2017)

At RN Drip, the medical staff understand that health information about you
is very personal and we are mandated by the Health Insurance Portability and Accountability Act (HIPAA)
to protecting your health information. We create a record of the care and services you receive from us,
and this record helps to provide you with quality care and to comply with certain legal requirements. This
Notice applies to all of the records of your care generated by us, and informs you about the ways in which
we may use and disclose information about you. We also describe your rights to the health information
we keep about you, and describe certain obligations we have regarding the use and disclosure of your
health information.

We are required by law to:

Make sure that health information that identifies you is kept private
Give you this Notice of our legal duties and privacy practices with respect to health information about you
Follow the terms of the Notice that is currently in effect

How we may use and disclose health information about you:

For Treatment
For Payment
For Healthcare operations
For appointment reminders
As required by law
Public Health risks
Health oversight activities
Lawsuits and disputes
Law enforcement
To avert a serious threat to health and safety
As required by the Military or Veterans and Workers Compensation
Coroners, health examiners and funeral directors
National Security and Intelligence activities
Protective Services for the President and others
Security Officials for Inmates
For any services provided by SunCoast Plastic Surgery

Your rights regarding Health Information about you:

Right to inspect and copy
Right to Amend
Right to Accounting of Disclosures
Right to Request Restrictions
Right to Request Confidential Communication

Your Medical Records: The original copy of your and/or electronic medical record is the property of RN
Drip. You may request a copy of your records to be transferred by completing a
medical records release form. As allowed by Georgia state law, there will be a fee for providing you with
this service. We require 14 business days from the date of your request to prepare and send your records
unless the records are for urgent of life threatening health issues.

Changes to this Notice: We reserve the right to change this Notice. We will post a copy of the current
notice in our facility with the current effective date.

Complaints: If you believe that your privacy rights have been violated, you may file a complaint with us. All
complaints must be in writing. Please contact the administrator at the location where you were treated to
file a complaint. For complete, detailed information regarding privacy laws, visit www.cms.gov/hipaa

Permission to Share your Health Information: We are required to follow certain federal guidelines and laws
regarding the confidentiality of your personal health information. One of these prevents us from discussing
anything in your medical file with anyone other than yourself or other medical personnel involved in your
care. If you would like us to discuss lab results or other personal information with your significant other,
family members, or any other individuals, please fill in their name and relationship to you in the section
listed below.

Acknowledgement of Receipt of the RN Drip, LLC HIPAA NOTICE OF PRIVACY PRACTICES:

We request that you sign this form acknowledging you have received, read, and reviewed the RN Drip, LLC
HIPAA Notice of Privacy Practices. If the patient is a minor, the legal guardian is automatically appointed by
law to provide/receive protected information on behalf of the patient. I will notify the staff of any changes or updates to this record. This acknowledgement will become part of your records.