In consideration of services provided by Apex Orthopaedics Spine & Neurology (“Provider”), the Patient or undersigned representative acting on behalf of the Patient agrees and consents to the following:

1. Consent to Routine Medical Treatment/Services. Patient consents to the rendering of Medical Treatment/Services as considered necessary and appropriate by the attending physician or other practitioner, a member of the Provider’s medical staff who has requested care and treatment of Patient, and others with staff privileges at Provider. Medical Treatment/Services may be performed by "Healthcare Professionals" (physicians, radiologist, nurses, technologists, technicians, physician assistants or other healthcare professionals). Patient authorizes the attending or other practitioner, the medical staff of Provider and Provider to provide Medical Treatment/Services ordered or requested by attending or another practitioner and those acting in his or her place. The consent to receive “Medical Treatment/Services” includes but is not limited to: out-patient care; examinations (MRI, x-ray or otherwise); laboratory procedures; medications; drugs; supplies; anesthesia; surgical procedures and medical treatments; recording/filming for internal purposes (Patient’s name, identification, diagnosis, treatment, performance improvement, education, safety, security) and other services which Patient may receive. Patient consents to treatment by Provider with the understanding that Patient will furnish accurate information regarding their injuries and will cooperate when referred to other physicians or medical facilities for examination or testing. Patient’s non-compliance with the plan of treatment may result in the refusal of further care and discharge from Provider.
2. Legal Relationship between Facility and Physician. Apex Orthopaedics Spine & Neurology, PLLC; Apex Orthopaedics Spine & Neurology of South Carolina, LLC; Georgia Spine & Orthopaedics, and Surgery Center of Roswell are physician owned facilities and your physician may have a financial interest in the center. Patient has the right to choose where Patient receives medical and surgical services including an entity in which Patient’s physician may have a financial relationship. Patient will not be treated differently by Patient’s physician if Patient opts to use a different If desired, Patient’sphysician can provide information about alternative providers. By accepting this acknowledgment of disclosure, PATIENT acknowledges that PATIENT has read and understand the foregoing notice regarding physician ownership.
3. Explanation of Risk and Treatment Alternatives. Patient acknowledges that the practice of medicine is not an exact science and that NO GUARANTEES OR ASSURANCES HAVE BEEN MADE TO THE PATIENT concerning the outcome and/or result of any Medical Treatment/Services. While routinely performed without incident, there may be material risks associated with each of these Medical Treatment/Services. Patient understands that it is not possible to list every risk for every Medical Treatment/Services and that this form only attempts to identify the most common material risks and the alternatives (if any) associated with the Medical Treatment/Services. Patient also understands that various Healthcare Professionals may have differing opinions as to what constitutes material risks and alternative Medical Treatment/Services. By signing this form: Patient consents to Healthcare Professionals performing Medical Treatment/Services as they may deem reasonably necessary or desirable in the exercise of their professional judgment, including those Medical Treatment/Services that may be unforeseen or not known to be needed at the time this consent is obtained; and Patient acknowledges that Patient has been informed in general terms of the nature and purpose of the Medical Treatment/Services; the material risks of the Medical Treatment/Services and practical alternatives to the Medical Treatment/Services. The Medical Treatment/Services may include, but are not limited to the following:
4. a)  Needle Sticks, such as shots, injections, intravenous lines or intravenous injections (lVs). The material risks associated with these types of Procedures include, but are not limited to, nerve damage, infection, infiltration (which is fluid leakage into surrounding tissue), disfiguring scar, loss of limb function, paralysis or partial paralysis or death. Alternatives to Needle Sticks (if available) include oral, rectal, nasal or topical medications (each of which may be less effective).
5. b)  Physical Tests, Assessments and Treatments such as vital signs, internal body examinations, wound cleansing, wound dressing, range of motion checks and other similar procedures. The material risks associated with these types of Procedures include, but are not limited to, allergic reactions, infection, severe loss of blood, muscular-skeletal or internal injuries, nerve damage, loss of limb function, paralysis or partial paralysis, disfiguring scar, worsening of the condition and death. Apart from using modified Procedures, no practical alternatives exist.
6. c)  Administration of Medications via appropriate route whether orally, rectally, topically or through Patient’s eyes, ears or nostrils, etc. The material risks associated with these types of Procedures include, but are not limited to, perforation, puncture, infection, allergic reaction, brain damage or death. Apart from varying the method of administration, no practical alternatives exist.
7. d) Insertion of Internal Tubes such as bladder catheterizations, nasogastric tubes, rectal tubes, drainage tubes, enemas, etc. The material risks associated with these types of Procedures include, but are not limited to, internal injuries, bleeding, infection, allergic reaction, loss of bladder control and/or difficulty urinating after catheter removal. Apart from external collection devices, no practical alternatives exist.
8. e)  Radiological Studies such as X-rays or MRI scans. The material risks associated with these types of Procedures include, but are not limited to, radiation exposure.

If Patient has any questions or concerns regarding these Medical Treatment/Services, Patient will ask Patient’s attending provider to provide Patient with additional information. Patient also understands that Patient’s attending or other provider may ask Patient to sign additional informed consent documents concerning these or other Medical Treatment/Services.

4. Healthcare Practitioners in Training. Patient recognizes that among those who may attend to Patient at Provider’s offices/clinics are medical, nursing and other health care personnel who are in training and who, unless specifically requested otherwise, may be present and participate in patient care activities as part of their medical education. There also may be present from time to time a medical product or medical device representative. Consent is hereby given for the presence and participation of such persons as deemed appropriate by the attending physician.
5. Authorization to Release Information. Provider is authorized to release information contained in the patient record. The information authorized to be released shall include, but is not limited to, infectious or contagious disease information, including HIV or AIDS-related evaluations, diagnosis or treatment; information about drug or alcohol abuse or treatment of same and/or psychiatric or psychological information. Patient waives any privilege pertaining to such confidential information. SIS, its agents and employees are hereby released from any and all liabilities, responsibilities, damages, claims and expenses arising from the release of information as authorized above. Reasons for releasing a Patient’s record include, but are not limited to, insurance company(s), their agents or other third party payor and/or government or social service agencies which may or will pay for any part of the medical/hospital expenses incurred or authorized by representatives of SIS, as mandated by law, or to alternate care providers, including community agencies and services, as ordered by Patient’s physician or as requested by Patient or Patient’s family for post-hospital care. PATIENT ACKNOWLEDGES AND AGREES THAT PATIENT’S RECORDS WILL BE AVAILABLE TO ALL OF PROVIDER’S AFFILIATED ENTITIES AND PROVIDERS, AND TO NON-PROVIDER AFFILIATED REFERRING PROVIDERS IN COMPLIANCE WITH THE PROVISIONS OF MEANINGFUL USE. Patient also agrees, in order for Provider to service accounts or to collect liabilities owed, to receive contact by telephone at any telephone number associated with their record, including wireless telephone numbers, which could result in charges to Patient. Provider or its agents may also contact Patient by sending text messages or emails, using any email address Patient provides. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.

Validity of Form. Patient acknowledges that a copy, or an electronic version of this document may be used in place of and is as valid as the original. Patient understands that the Healthcare Professionals participating in the Patient’s care will rely on Patient’s documented medical history, as well as other information obtained from Patient, Patient’s family or others having knowledge about Patient, in determining whether to perform or recommend the Procedures; therefore, Patient agrees to provide accurate and complete information about Patient’s medical history and conditions.

Patient has read and understood and accepted the terms of this document and the undersigned is the Patient, the Patient’s legal representative or is duly authorized by the Patient as the Patient’s general agent to sign this form.  

I understand that at my direction my Provider will transmit my prescriptions electronically as permitted, to the pharmacy that I delegate as my primary pharmacy provider. Prescription data collected will be stored in Provider’s practice electronic medical records system and will become a part of my personal medical record. I hereby give permission to allow Provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers. By signing this consent, I give Provider permission to collect and give my pharmacy and health insurer permission to disclose information about my prescriptions that have been filled at any pharmacy or covered by any health plan. This includes prescriptions to treat AIDS/HIV and medications used to treat mental health issues.

THE INFORMATION I HAVE PROVIDED IS TRUE, ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND ABILITY. I HAVE READ/COMPLETED OR HAVE HAD THIS ACKNOWLEDGEMENT AND CONSENT FORM READ/ COMPLETED FOR ME AND IT HAS BEEN EXPLAINED TO MY SATISFACTION AND APPLIES TO ALL MEDICAL PROFESSIONALS EMPLOYED BY PROVIDER.

Patient assigns and appoints Apex Orthopaedics Spine & Neurology (“Provider”), as its authorized representative and billing agent with the right to pursue payment for benefits, and take any and all necessary steps, including pursuing administrative appeals, requesting disclosures and remedies, filing suit and all causes of action wholly in my stand for benefit payment of all medical benefits otherwise payable to the Patient for medical services, treatments, therapies, and/or medications rendered or provided by the Provider under the Plan, regardless of the Provider’s managed care network participation status. The Patient hereby appoints the Provider, its billing agent and/or the Patient’s appointed business associates, the Patient’s rights, title, and interests in and to, and related to the recovery of, any and all benefits which the Patient is entitled to receive under the Plan or insurance policy and authorizes the Provider to release all medial information necessary to pursue and process the Patient’s benefits and claims thereunder. Patient certifies that the health insurance information that Patient provided is accurate and that Patient is responsible for keeping it updated. Patient hereby authorize Provider to submit claims on Patient’s behalf to the benefit plan (or its administrator) to be paid in full compliance of governing laws. Patient also hereby instructs its benefits plan (or its administrator) to pay the Provider directly for services rendered to Patient. To the extent that my current policy prohibits direct payment to provider, Patient hereby instructs and directs its benefit plan (or its administrator) to provide governing plan documentation stating such non-assignment to Patient and the Provider upon request and its standing to governing laws. Upon proof of such non-assignment, Patient instructs benefit plan (or its administrator) to make check payable to Patient and mail it directly to Provider. Patient understands there are state and federal consumer protections that support even for out of network providers that may be associated with Patient’s care or surgery, that Patient is responsible for co-payments, co-insurance, and deductibles at no more than Patient’s in-network cost share rate. Patient understands, agrees and hereby certifies that Patient is obligated to pay, as charge and billed for global service charges, regardless of if the above services are covered under Patient’s health insurance or plan. Patient understands that “Deductible” is defined, under the Uniform Glossary from ERISA & the Patient Protection & Affordable Care Act (“ACA”) as: “The amount [Patient] owes for healthcare services [Patient’s] health insurance or plan covers before [Patient’s] health insurance or plan begins to pay,” and that Patient has no knowledge of any plan exclusion or limitation for the charges for healthcare services rendered by the above listed provider, in case that Patient can’t afford to pay 100% deductible. Patient understands the payments are due at the time of the services unless otherwise applicable to any PPO or ACA discount once Patient’s claim for benefits is processed in full compliance with plan terms and governing laws. Patient understands Patient is fully protected against any unexpected medical bills or charges by my provider’s appliable ACA or indigency discount policy; including any non-complaint or arbitrary and capricious PPO discount of Re-pricing Discounts received from Patient’s health insurance plan. Patient’s satisfaction is guaranteed in connection with Provider’s proactive reasonable efforts to collect or make a good faith determination for ACA Discount qualifications solely based on Patient’s unique ability to pay and individual health need. Patient hereby assigns billed charges for healthcare services rendered as Patient’s legal claims to the above listed Provider as full payment, as Patient authorized representative, and an ERISA or ACA claimant, to claim or legally pursue proper payment of benefits from my health plan or insurance.

Patient hereby designates, authorizes and appoints Provider, its attorney or other designated business associate and a Patient’s authorized representative to: (1) release any information necessary to Patient’s health benefit plan (or its administer) regarding Patient’s illness and treatments; (2) process insurance claims generated in the course of examination or treatment; (3) To file and participate in any administrative or judicial review process; (4) to give the provider and its attorneys standing to pursue payment and file suit for benefits and any fiduciary breach and all causes of action, wholly in Patient’s stead; (6) to pursue a claim for benefits and to recover all applicable penalties for any fiduciary breach and all causes of action available under ERISA and Section 502, 27 § U.S.C. 1132(a); (5) to pursue all necessary benefit payments, appeal rights, remedies and all causes of action, wholly in Patient’s stead; (6) to pursue a claim for benefits and to recover all applicable penalties for any fiduciary breach or failure by Patient’s plan, its fiduciary and/or its claims administrator to comply with 29 USC § 1132 and (7) allow a photocopy of Patient’s signature to be used to process insurance claims. This authorization includes all entitled benefit payments, rights and remedies due under Patient’s governing Health and Welfare Plan or policy, to include all benefits entitled for all services rendered and ordered by Patient’s treating physician. This authorization will remain in effect until all benefits are paid in full compliance of applicable federal and state laws. Patient hereby confirms and ratifies all actions taken by Patient’s Provider, its attorneys or designated business associates to make any request, file and obtain appeals information, receive any notice in connection with patient’s healthcare services, benefits, appeals, take legal action or other rights, wholly in Patient’s stead. Further, Patient hereby authorizes Patient’s plan administrator, fiduciary, insurer, and/or attorney to release to the above-named health care provider or its designated business associated in any and all relevant Plans and claim documents, requested disclosures, complete insurance policy, and/or settlement information upon request from Provider, its attorneys or designated business associate in order to secure and claim such medical benefits. Patient authorizes the release or disclosure of Patient’s protected health information to Patient’s authorized representative in order to secure and claim medical benefits due: (1) obtain information or submit evidence regarding the claim to the same extent as Patient; (2) make statements about facts or law; (3) act as Patient’s authorized representative in connection with filing, providing or receiving notice of any claim or appeal proceedings, to include any external review by applicable state and Federal External Review Process. I understand that I will be held financially responsible for all fees accumulated for collection agency fees. Administrative fees, attorney fees and court costs incurred by the provider listed above for any delinquent account requiring outside collection assistance, to the fullest extent of the law. Patient understands revocation of this appointment will not affect any action taken in reliance on this appointment before Patient’s written notice of revocation is received. Unless revoked in writing, this assignment is valid for any and all requested administrative and judicial reviews rightfully due to Patient under Patient’s governing plan or policy and to the fullest extent permitted by law. Patient, by signing this form, confirms appointment of authorized representative, the scope of Patient’s authorized representative’s authority, and the option of revoking of this appointment.

Patient understands Provider will attempt to obtain eligibility information, authorizations, and referrals on Patient’s behalf. Patient understands that it is in Patient’s best interest to verify with Patient’s insurance carrier what Patient’s benefits are and if  Provider is participating on Patient’s plan. Provider does not guarantee benefits or coverage at the time of service. Patient also understands that any amounts not paid by Patient’s health insurance or plan is Patient’s responsibility and such payment is due at the time of service.

Patient hereby assigns and authorizes payment directly to Provider of: (i) any private healthcare insurance, (ii) medicalpayment insurance, (iii) injury benefit due because of liability of a third-party, and (iv) proceeds of all claims resultingfrom the liability of a third party, payable by any party, organization, attorney, etc., to or for Patient, unless and until Patient’s account with Provider for the services or series of related services provided by the Provider (collectively, the “Services”) is paid in full, upon discharge or completion of the Services. Patient hereby authorizes Provider to apply and file for allsuch payments referenced herein on Patient’s behalf, and direct that such payments be made directly to Provider.

Patient understands that by receiving services provided by Provider (collectively, the “Services”) PATIENT is personallyresponsible for any portion of the Provider’s invoice(s) for Services that remains outstanding. Patient further agrees to execute any necessary documents to direct all third-party benefits and other payments for Services to Provider.

Patient understands that Provider has the right to disclose to an outside collection agency or attorney all relevant personal and account information necessary to collect payment for services rendered. If a lawsuit is filed to collect on Patient’s account, exclusive jurisdiction shall be in the state and federal courts of North Carolina. Patient waves all objections to personal jurisdiction and venue in North Carolina. Patient agrees to pay Provider’s reasonable attorneys’ fees and costs incurred collecting on any outstanding amounts due to Provider.

In accordance with the Health Insurance Portability and Accountability Act (HIPAA), by accepting this form, Patientacknowledges that Patient was given access to and offered a copy of the Notice of Privacy Practices for Apex Orthopaedics Spine & Neurology.

Patient hereby authorize Provider to leave Protected Heath Information (“PHI”) pertaining to Patient’s care by voicemail/email/text and will assume responsibility to notify them whenever this information changes. Patient authorizesProvider to leave messages with the person(s) Patient has designated as Patient’s approved contacts or emergency contacts. Patient understands that PHI used or disclosed pursuant to this Authorization may be subject to re-disclosure bythe recipient and no longer protected by Federal or State Law. Patient understands that Patient have the right to revokethis authorization at any time. Patient understands that in order to revoke this authorization, Patient must do so inwriting and present Patient’s revocation to Provider. Patient understands that the revocation will not apply to information that has already been used or disclosed in response to this authorization. Patient understands that this authorization isvalid unless and until written notice is provided to revoke this authorization. Patient understands that Provider cannot require Patient to sign this authorization as a condition of treatment unless the provision of health care by Provider is for the sole purpose of creating PHI for disclosure to a third party legally authorized to receive such information.

By providing a telephone number, Patient expressly consent and authorize SIS, any practitioner or clinical provider as well as any of their related entities, agents, or contractors including but not limited to schedulers, debt collectors, and other contracted staff (collectively referred to herein as “Provider”) to contact Patient through the use of text messages and any dialing equipment (including a dialer, automatic telephone dial system, and/or interactive voice recognition system) and/or artificial or prerecorded voice or message. Patient expressly agree that such automated calls and/or text messages may be made to any telephone number (including numbers assigned to any cellular or other service for which Patient may be charged for the call) used by or associated with Patient and obtained through any source including but not limited to any number Patient is providing today, have provided previously, or may provide in the future in connection with the medical goods and services and/or Patient’s account. By providing this express consent, Patient specifically waives any claim Patient may have to the making of such calls, including any claims under the federal or state law and specifically any claim under the Telephone Consumer Protection Act, 47 U.S.C. § 227. By providing a telephone number, Patient represent that Patient is the subscriber or owner or have the authority to use and provider consent to call the number.

By providing Patient’s email address now or at any time in the future in connection with the medical goods and services provided and/or Patient’s account, Patient expressly opt-in to the receipt of email communications from Provider for or related to the medical goods or services provided, Patient’s account, and other services such as financial, clinical, and education information including news, changes to health care laws, health coverage, care follow-up, and other health care opportunities, goods, and services. By providing this express consent, Patient specifically waives any claim PATIENT may have for the sending of such emails, including any claim under federal or state law and any claim under the CAN-SPAM Act, 15 U.S.C. § 7701, et. seq. By providing an email address, Patient represents that Patient is the subscriber or owner of have the authority to use and provider consent to contact the email address.

Patient understands that providing a telephone and/or email address is not a condition of receiving medical services. Patientunderstands that Patient may revoke Patient’s consent to contact at any time by directly contacting Provider or using the opt-out method that will be identified in the applicable communication. Patient also understands that it is Patient’s responsibility to notify Provider immediately of any change in telephone number or email address.

I authorize the release of medical record(s) of the above person. This information is being released to APEX ORTHOPAEDICS, SPINE & NEUROLOGY for purpose of continued medical care.

“I understand that I have the right to revoke this authorization at any time by presenting a written revocation to the Medical Records Director or designee. I understand that the revocation will not apply to any information that has already been released in response to this authorization.”

This expiration will expire one (1) year from the date of my signature.

“I have read and understand the contents of this authorization and I confirm that the health care provider may use/disclose my protected health information to the persons and/or organization named above.”

Please release to:

Apex Orthopaedics, Spine & Neurology

Dr. Erik Bendiks, Dr. Joshua Levy, Dr. Thai Truong,

11650 Alpharetta Hwy

Roswell, GA 30076

Email: clinical@apexosn.com

Phone: 704-272-3880

Fax: 704-208-4159

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.

This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act (HIPAA). This Privacy Notice describes how we may use and disclose your protected healthinformation to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information in some cases. Your “protected health information” means any written and oral health information about you, including demographic data thatcan be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.

1. Uses and Disclosures of Protected Health Information

The Organizations may use your protected health information for purposes of providing treatment, obtaining payment fortreatment, and conducting health care operations. Your protected health information may be used or disclosed only for these purposes unless the facility has obtained your authorization, or the use or disclosure is otherwise permitted by the HIPAA privacy regulations or state law. Disclosures of your protected health information for the purposes described in this Privacy Notice may be made in writing, orally, or by facsimile.

• We will use and disclose your protected health information to provide, coordinate, or manageyour health care and any related services.
• Your protected health information will be used, as needed, to obtain payment for the services that we provide.
• We may use or disclose your protected health information, as necessary, for our own health care operations to facilitate the function of Provider and to provide quality care to all patients.
• Other Uses and Disclosures. As part of treatment, payment and health care operations, we may also use or disclose yourprotected health

1. Uses and Disclosures beyond Treatment, Payment and Health Care Operations Permitted without Authorization or Opportunity to Object

Federal privacy rules allow us to use or disclose your protected health information without your permission orauthorization for several reasons including the following:

• When Legally
• When There Are Risks to Public
• To Report Suspected Abuse, Neglect or Domestic
• To Conduct Health Oversight
• In Connection with Judicial and Administrative
• For Law Enforcement
• For Research
• In the Event of a Serious Threat to Health or
• For Specified Government
• For Worker’s

The facility may release your health information to comply with worker’s compensation laws or similar programs.

• USES AND DISCLOSURES PERMITTED WITHOUT AUTHORIZATIONS BUT WITH OPPORTUNITY TO OBJECT

We may disclose your protected health information to your family member if it is directly relevant to the person’s involvement in your care or payment related to your care. We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your location, condition or death.

You may object to these disclosures. If you do not object to these disclosures, in the exercise of our professional judgment, that it is in your best interest for us to make disclosure of information that is directly relevant to that person’sinvolvement with your care, we may disclose your protected health information as described.

1. USES AND DISCLOSURES WHICH YOU AUTHORIZE

Other than stated above, we will not disclose your health information other than with your written authorization. You mayrevoke your authorization in writing at any time except to the extent that we have acted in reliance upon the authorization. We specifically require your written authorization for marketing or the sale of your protected health information. If our facility maintains psychotherapy notes, we will require your written authorization for the use or disclosure of psychotherapy notes other than by the creator of those notes, by the facility for its training programs or for the facility to defend itself in a legal action brought by you.

1. YOUR RIGHTS

You have the following rights regarding your health information:

• The right to inspect and copy your protected health information. You may inspect and obtain a copy of your protected health information that is contained in a designated record set for as long as we maintain the protected health A“designated record set” contains medical and billing records and any other records that your surgeon and the facility uses for making decisions about you. If information in a “ designated record set” is maintained electronically, you may request an electronic copy in a form and format of your choice that is readily producible or, if the form/format is not readily producible, you will be given a readable electronic copy in a timely manner not to exceed 60 days. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to a law that prohibits access to protected health information. Depending on the circumstances, you may have the right to have a decision to deny access reviewed.

We may deny your request to inspect or copy your protected health information if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision.

To inspect and copy your medical information, you must submit a written request to the Privacy Officer whose contact information is listed on the last page of this Privacy Notice. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request. Please contact our Medical Records Custodian if you have questions about access to your medical record.

• The right to request a restriction on uses and disclosures of your protected health You may ask us not touse or disclose certain parts of your protected health information for the purposes of treatment, payment and health care operation. You may request that we do not file a claim to your health plan if an agreed upon amount is paid out-of-pocket. You may also request that we not disclose your health information to family members or friends who maybe involved in your care or for notification purposes as described in this Privacy Notice. Your request must state the specific restriction requested and to whom you want the restriction to apply.

The facility is not required to agree to a restriction that you may request unless your request related to a disclosure to a health plan for items or services that were paid in full by you or someone other than the health plan and thedisclosure is not required by law. We will notify you if we deny your request to a restriction. If the facility does agreeto the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting the Privacy Officer using the contact information below.

• The right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to request that we communicate with you in certain ways. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not require you to provide an explanationfor your Requests must be made in writing to our Privacy Officer using the contact information below.
• The right to request amendments to your protected health information. You may request an amendment of protected health information about you in a designated record set for as long as we maintain this Your request may be denied if we did not create the PHI, if the amendment is not part of normal record keeping of PHI, and if theamendment would never be included for inspection by any other group or party and if we believe the record isaccurate and complete without the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copyof any such rebuttal. Requests for amendment must be in writing and must be directed to our Privacy Officer whose contact information is listed on the last page of this Privacy Notice. In this written request, you must also provide a reason to support the requested amendment.
• The right to receive an You have the right to request an accounting of certain disclosures of your protectedhealth information made by the facility. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures for a facility directory, to friends or family members involved in your care, or certain other disclosures we are permitted to make without yourauthorization. The request for an accounting must be made in writing to our Privacy Officer. The request shouldspecify the time sought for the accounting. Accounting requests may not be made for periods of time more than six years. We will provide the first accounting you request in any 12-month period without charge, Subsequent accounting requests may be subject to a reasonable cost-based fee.
• The right to obtain a paper copy of this Upon request, we will provide a separate paper copy of this noticeeven if you have already received a copy of the notice or have agreed to accept this notice electronically.
• PATIENT understand that, by law, Patient’s medical record belongs to Provider. The right to request a copy ofyour medical records in accordance with State and federal Any requests for copies of paper medical records willbe processed within 60 days.

1. OUR DUTIES

The facility is required by law to maintain the privacy or your health information and report to you any breach of unsecured protected health information. We are also required to provide you with this Privacy Notice of our duties and privacy practices. We are required to abide by terms of this Notice as may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all future protected health information that we maintain. If the facility changes this Notice, we will post notification at each office location and provide a copy of the revised Notice on our website.

• COMPLAINTS

You have the right to express complaints to the facility and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to the facility by contacting the Privacy Officer verbally or in writing, using the contact information below. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

• CONTACT PERSON

The facility’s  contact person for all issues regarding patient privacy and your rights under the federal privacy standards is the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer. If you feel that your privacy rights have been violated by this facility you may submit a complaint to:

Apex Orthopaedics Spine and Neurology

Attn: Privacy Officer

10502 Park Road, Ste 120

Charlotte, NC 28210

Phone: 704-272-3880

Anonymous HIPAA Hotline: 844-333-0850

If you are unable to get your issue resolved, you may 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, or by calling 1-877-696-6775.