Notice of Privacy Practices

Who We Are

This notice is given by Moonshot Medical and Performance LLC, 542 Busse Hwy, Park Ridge, IL 60068. It applies to the health information we create or receive about you as a patient, including information held by our clinicians, staff and the companies that help us run the practice. In this notice, "we", "us" and "our" mean Moonshot Medical and Performance LLC.

Our Duties

We are required by law to:

• Keep the privacy and security of your protected health information.
• Give you this notice of our legal duties and privacy practices.
• Follow the terms of the notice that is currently in effect.
• Tell you promptly if a breach occurs that may have compromised the privacy or security of your information.

We will not use or share your information other than as described here unless you tell us we can in writing.

How We May Use and Disclose Your Health Information

The following describes the ways we may use and share your health information without your written authorization. Not every use in a category is listed, but every use we make falls within one of these categories.

• Treatment. We use your information to provide and coordinate your care, and we share it with other professionals treating you. For example, your clinician may send an order to a laboratory or a prescription to a pharmacy.
• Payment. We use and share your information to bill and get paid for the services we provide, including from you, a health plan or another payer. For example, we may give your health plan information about a visit so it can reimburse you or us, or share information with our payment processor to complete a charge.
• Health care operations. We use and share your information to run our practice, improve your care and contact you when necessary. For example, we review records to evaluate the quality of care and to train staff.
• Appointment reminders and treatment options. We may contact you to remind you of an appointment, or to tell you about treatment alternatives or health-related services that may interest you.
• Family and friends involved in your care. We may share information with a family member, friend or other person you identify who is involved in your care or helps pay for it, unless you tell us not to. If you are not present or cannot agree, we may share what we believe is in your best interest.
• Disaster relief. We may share information with an organization assisting in a disaster relief effort so your family can be told about your condition and location.
• Business associates. We share information with companies that perform services for us, such as our electronic health record, laboratory, billing and messaging vendors. Each one signs a business associate agreement requiring it to protect your information.
• As required by law. We will share your information when federal, state or local law requires it.
• Public health. We may share information to prevent or control disease, injury or disability; to report births and deaths; to report reactions to medications or problems with products to the FDA; and to notify people who may have been exposed to a disease.
• Abuse or neglect. We may share information with the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence, to the extent the law requires or allows.
• Health oversight. We may share information with agencies for activities authorized by law, such as audits, investigations, inspections and licensure.
• Legal proceedings. We may share information in response to a court or administrative order, or in response to a subpoena or other lawful process when the law allows.
• Law enforcement. We may share information with law enforcement officials for purposes the law allows, such as identifying or locating a suspect, fugitive, material witness or missing person, or reporting a crime on our premises.
• Coroners, medical examiners and funeral directors. We may share information with a coroner or medical examiner to identify a person or determine a cause of death, and with funeral directors as needed for their duties.
• Organ and tissue donation. If you are an organ or tissue donor, we may share information with organizations that handle organ, eye or tissue procurement or transplantation.
• Research. We may use or share information for research when an institutional review board or privacy board has approved the use and set protections for your privacy, or as otherwise allowed by law.
• To avert a serious threat to health or safety. We may share information when necessary to prevent a serious and imminent threat to your health and safety or that of another person or the public.
• Workers' compensation. We may share information for workers' compensation or similar programs that provide benefits for work-related injuries or illness.
• Military and national security. If you are a member of the armed forces, we may share information as required by military command authorities. We may share information with authorized federal officials for intelligence, counterintelligence, protective services for the President and other national security activities authorized by law.
• Inmates. If you are an inmate of a correctional institution or in the custody of a law enforcement official, we may share information with the institution or official when necessary for your care, your health and safety, or the safety of others.

Where Illinois law gives certain information greater protection than HIPAA, such as mental health, HIV or genetic testing records, we follow the stricter law. Substance use disorder treatment records covered by federal law (42 CFR Part 2) receive the additional protection that law requires.

Your Rights

You have the following rights regarding your health information. To use any of them, contact our Privacy Officer using the information at the end of this notice.

• Inspect and copy. You may ask to see or get an electronic or paper copy of your medical and billing records. We will respond within 30 days and may charge a reasonable, cost-based fee.
• Amend. If you believe information in your record is incorrect or incomplete, you may ask us to amend it. We may say no, but we will tell you why in writing within 60 days.
• Accounting of disclosures. You may ask for a list of the times we shared your information in the six years before your request, who we shared it with and why. The list will not include disclosures for treatment, payment, health care operations or ones you authorized. We provide one list a year free and may charge a reasonable, cost-based fee for more.
• Request restrictions. You may ask us not to use or share certain information for treatment, payment or 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 item in full out of pocket, you may ask us not to share that information with your health plan for payment or operations, and we will agree unless the law requires us to share it.
• Confidential communications. You may ask us to contact you in a specific way (for example, a home or office phone) or at a different address. We will agree to all reasonable requests.
• Paper copy of this notice. You may ask for a paper copy of this notice at any time, even if you agreed to receive it electronically.
• Breach notification. You have the right to be notified if a breach of your unsecured health information occurs.
• Choose someone to act for you. If you have given someone medical power of attorney, or someone is your legal guardian, that person can exercise your rights and make choices about your health information.

Changes to 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 on request, in our office and on this website, with its effective date at the top.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us by contacting our Privacy Officer at Moonshot Medical and Performance LLC, 542 Busse Hwy, Park Ridge, IL 60068, or by email at hello@moonshotmp.com.

You may also 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, by calling 1-800-368-1019, or online at www.hhs.gov/ocr/complaints.

We will not retaliate against you for filing a complaint.