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.

Who Will Follow This Notice

Helium Medical and the employees and staff of each Helium Medical Facility, provide healthcare to patients, together with other healthcare providers and other organizations. This Notice applies to the following persons and entities, who have agreed to be bound by this Notice:

• Helium Medical employees, staff and other personnel, who may need to access your information to perform their job functions.

• Members of the medical staff of Helium Medical, as well as other health care professionals who provide health care services at Helium Medical.

• Any member of a volunteer group we allow to help you while you are receiving care.

This Notice applies to all of the records related to your health care provided to you at Helium Medical.

Our Pledge Regarding Medical Information

We understand that medical information about you and your health is personal. Protecting medical information about you is important. We need this record to provide you with quality care and to comply with certain regulatory requirements. This Notice will tell you about the ways in which we may use and disclose medical information about you. This Notice also describes your rights, and certain obligations we have regarding the use and disclosure of your medical information. We are required by law to:

• Keep medical information that identifies you private;

• Give you this Notice of our legal duties and privacy practices with respect to medical information about you; and

• Follow the terms of the Notice that is currently

How We May Use and Disclose Medical Information About You

The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to healthcare providers who are involved in taking care of you.
Payment: We may use and disclose medical information about you so that the treatment and services you receive may be billed to, and payment may be collected from, you, an insurance company or a third party. For example, we may need to give your health plan information about care you received at a Helium Medical so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about a treatment you are going to receive or need in order to obtain prior approval or to determine whether your insurance will cover the treatment.
Health Care Operations: We may use and disclose medical information about you for our health care operations. These uses and disclosures are necessary to make sure that all of our patients receive quality care.
Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care.
Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-Related Benefits and Services: We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
As Required by Law: We will disclose medical information about you when required to do so by federal, state or local law.
Law Enforcement: If permitted by applicable law, we may release medical information if asked to do so by a law enforcement official:

• in response to a court order, subpoena, warrant, summons or similar process;

• to identify or locate a suspect, fugitive, material witness, or missing person;

• about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;

• about a death we believe may be the result of criminal conduct;

• about criminal conduct at the hospital; and

• in emergency circumstances to report a crime, the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Note on Other Restrictions: Please be aware that certain federal or state laws may have more strict requirements on how we use and disclose your medical information. If there are stricter requirements, even for the purposes listed above, we will not disclose your medical information without your written permission, or as otherwise permitted or required by such laws. For example, we will not disclose your HIV test results without obtaining your written permission, except as permitted by state law. We may also be restricted by law to obtain your written permission to use and disclose your information related to treatment for certain conditions such as mental illness, or alcohol or drug abuse.

Your Rights Regarding Medical Information About You

You have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy. You have the right to inspect and copy the information that we have about you that may be used to make decisions about you and your care, including your medical and billing records. We may deny your request to inspect and copy in certain very limited circumstances. To inspect and copy your information that may be used to make decisions about you, please submit your request in writing If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
Right to Amend: If you feel that information, we have about you is incorrect or incomplete, 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 Helium Medical.
Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations purposes. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care.
Right to Authorize or Refuse to Authorize Other Uses and Disclosures of Medical Information: Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us your authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time.
Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.
Complaints: If you believe your privacy rights have been violated, you may file a complaint with us and with the Secretary of the United States Department of Health and Human Services. For information on filing a complaint with us, contact us at 346-762-8822

We schedule our appointments so that each patient receives the right amount of time to be seen by our physicians and staff. That’s why it is very important that you keep your scheduled appointment with us and arrive on time.

As a courtesy, and to help patients remember their scheduled appointments, HELIUM MEDICAL will place a call within 2-5 days and send a text message reminder 1 day in advance of the appointment time. If your schedule changes and you cannot keep your appointment, please contact us so we may reschedule you, and accommodate those patients who are waiting for an appointment.

As a courtesy to our office as well as to those patients who are waiting to schedule with the physician, please give us at least 24 hours’ notice.

If you do not cancel or reschedule your appointment with at least 24 hours’ notice, we may assess a $25.00 “no-show” service charge to your account. This “no-show charge” is not reimbursable by your insurance company and it’s due before ANY further service is rendered. You will be billed directly.

I understand the “no-show” policy of HELIUM MEDICAL and agree to PAY a charged $25.00 for any no-show of a scheduled appointment. I understand that I must cancel or reschedule any appointment at least 24 hours in advance to avoid a potential no-show charge.

After three consecutive no-shows to your appointment, our practice may decide to terminate its relationship with you.

1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.

2. I understand that I will not be physically in the same room as my health care provider. I will be notified of, and my consent obtained for anyone other than my healthcare provider, present in the room.

3. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.

a. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.

4. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.

a. I may revoke my right at any time by contacting Helium Medical at 346-762-8822.

5. I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.

6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes.

a. I understand that my insurance carrier will have access to my medical records for quality review/audit.

b. I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my telemedicine visit.

c. I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits.

7. I understand that this document will become a part of my medical record.

By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s).