Privacy Policy

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.

Your Information. Your Rights. Our Responsibilities.

We are required by law to maintain the privacy and security of your protected health information ("PHI"), to give you this Notice, and to follow the duties and privacy practices in this Notice and any updates to it. PHI is information that identifies you and relates to your past, present, or future physical or mental health or condition, the provision of health care to you, or payment for that care.

Your Rights

• Get an electronic or paper copy of your medical record You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

• Ask us to correct your medical record You can ask us to correct health information you think is incorrect or incomplete. We may say

“no” to your request, but we will tell you why in writing within 60 days.

• Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.

• Ask us to limit what we use or share You can ask us not to use or share certain information for treatment, payment, or health care operations. We are not required to agree, and we may say “no” if it would affect your care. If you pay for a service or health care item out of pocket in full, you can ask us not to share that information with your health insurer for payment or operations, unless we are required by law to share.

• Get a list (accounting) of disclosures You can ask for a list of the times we have shared your information for six years prior to the date you ask, who we shared it with, and why. We will include all disclosures except those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another within 12 months.

• Get a copy of this Notice You can ask for a paper copy of this Notice at any time, even if you agreed to receive the Notice electronically. We will provide you with a paper copy promptly.

• Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority before we take any action.

• File a complaint if you feel your rights are violated You can complain if you feel we have violated your rights by contacting our Privacy Officer using the information at the end of this Notice. You can also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR), by mail at 200 Independence Avenue, S.W., Washington, D.C. 20201, by phone at 1-877-696-6775, or online at https://www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations below, tell us and we will follow your instructions.

• Sharing information with your family, close friends, or others involved in your care

• Sharing information in a disaster relief situation • Including your information in a hospital directory (if applicable)

In these cases we will not share your information without your written permission: • Marketing purposes

• Sale of your information • Most sharing of psychotherapy notes

Fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again. We will not use or disclose any Substance Use Disorder (Part 2) records for fundraising without your written consent, and you will always have a clear, conspicuous opportunity to opt out of any fundraising communications.

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways:

• Treat you

We can use your health information and share it with other professionals who are treating you. • Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

• Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities. How else can we use or share your health information? We are allowed or required to share your information in other ways—usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

• Help with public health and safety issues We can share information about you for certain situations such as preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect, or domestic violence; and preventing or reducing a serious threat to anyone’s health or safety.

• Do research We can use or share your information for health research as permitted by law.

• Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services to confirm our compliance with federal privacy law.

• Respond to organ and tissue donation requests We can share information about you with organ procurement organizations.

• Work with a medical examiner or funeral director

We can share information with a coroner, medical examiner, or funeral director when an individual dies.

• Address workers’ compensation, law enforcement, and other government requests. We can use or share information about you for workers’ compensation claims; for law enforcement purposes or with a law enforcement official; with health oversight agencies for activities authorized by law; and for special government functions such as military, national security, and presidential protective services.

• Respond to lawsuits and legal actions

We can share information about you in response to a court or administrative order, or in response to a subpoena, discovery request, or other lawful process as permitted by law.

Additional Protections for Substance Use Disorder (SUD) Records (42 C.F.R. Part 2)

Some records we create, receive, or maintain may be protected by federal law at 42 C.F.R. Part 2 (“Part 2”), which provides extra privacy protections for records relating to substance use disorder diagnosis, treatment, or referral for treatment that originate from a federally assisted SUD program.

Part 2 records generally may not be used or disclosed without your written consent except in limited circumstances expressly permitted by Part 2. When you authorize a disclosure of Part 2 records, the recipient is prohibited from redisclosing those records unless further disclosure is allowed by Part 2 or another law.

We will not use or disclose Part 2 program records in any civil, criminal, administrative, or legislative proceeding against you without your written consent or a specific court order that complies with Part 2 and is issued after you have received notice and an opportunity to be heard. Fundraising: If we contact you about fundraising, we will not use or disclose Part 2 records for that purpose unless you have given written consent, and you will always have a clear and conspicuous opportunity to opt out of further fundraising communications. Your other HIPAA rights described in this Notice also apply to Part 2 records, to the extent consistent with Part 2. If there is a conflict between HIPAA and Part 2 regarding SUD records, Part 2 controls.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this Notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you give us permission, you may revoke it at any time in writing.

Changes to the Terms of This Notice

We may change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website. The effective date is shown at the end of this Notice.

Questions, Requests, and Complaints

If you have questions about this Notice, want to exercise your rights, or want to file a complaint, contact our Privacy Officer:

Privacy Officer: Nina Bonifacio

Mailing Address: 2581 Washington Road, Suite 221, Pittsburgh, PA 15241

Phone: 214-864-8537

Email: nbonifacio@mytownhealthpartners.com

You may also file a complaint with the U.S. Department of Health & Human Services, Office for Civil Rights, at 200 Independence Avenue, S.W., Washington, D.C. 20201, 1-877-696-6775, or online at https://www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint. Effective Date: January 19, 2026

Cookeville Medical Clinic RHC

✆ Phone (appointments): 931-528-8899

Address: 225 N Willow Ave, Suite 3, Cookeville, TN 38501

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