IOP SERVICES, LLC
Annual Consent and Release of Information

1. USE AND DISCLOSURE OF INFORMATION:
I hereby acknowledge that IOP Services, LLC gave or offered me a copy of the Notice of Privacy Practices. The Notice of Privacy Practices explains how my information may be used or disclosed.

2. ASSIGNMENT OF MEDICARE AND/ OR THIRD-PARTY INSURANCE BENEFITS:
I agree with any benefits of any type arising out of any federal or state program or any policy of insurance or me, or any other party liable to me, are hereby assigned IOP Services, LLC that provide treatment or clinical oversight for rendered services for which an assignment is applicable. I understand that I am financially responsible to IOP Services, LLC that provide treatment or clinical oversight for charges not covered by this authorization. I certify that the information given by me is accurate and complete.

3. FINANCIAL AGREEMENT:
I agree, whether I sign as agent or as patient, that in consideration of the services be rendered to the patient, I hereby individually obligate myself to pay the account of IOP Services, LLC that provide treatment or clinical oversight in accordance with the regular rates and terms of said providers. Should the account be referred for collection, I shall pay reasonable attorney’s fees and collection expenses. All delinquent accounts may bear interest at the legal rate. I recognize that all healthcare providers that provide treatment or clinical oversight to the patient may submit a separate statement or account form for each such health care provider.

4. CONSENT TO TREATMENT AND TESTS:
I hereby consent to and authorize the administration and performance of all operations and treatments, which in the judgement of my physicians/ healthcare providers may be considered necessary or advisable and/ or the administration of any anesthetics and blood, plasma or related agents including the drawing of blood for diagnostic tests. I understand that any rf all tissue and body fluids removed may be destroyed. Further, I give permission to admit students or others to observe my care as are sanctioned in the policies established by the Physician Leadership Committee (PLC) of IOP Services, LLC. I understand that I may revoke this consent for observation at any time by verbally informing my caregiver.

5. MEDICAL RECORD RELEASE TO ALTERNATE CONTACT:
To assist in communicating results, appointments, and other information with you effectively, please indicate your preferences for communicating this information to you below.


IOP SERVICES, LLC
IOP SERVICES LLC NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

IOP Services, LLC is committed to protecting your health information. The medical information we create and maintain is known as Protected Health Information, or PHI. PHI is information that individually identifies you and that we create or get from you or from another health care provider, health plan, your employer, or a health care clearinghouse and that relates to (1) your past, present, or future physical or mental health or conditions, (2) the provision of health care to you, or (3) the past, present, or future payment for your health care. We are required by Federal and State laws to protect the privacy of your medical information and obtain a signed authorization by you for certain disclosures. We are required by law to provide you with this Notice of our legal duties and privacy practices with respect to your medical health information. This Notice explains how we may legally use and disclose your PHI and your rights regarding the privacy of your PHI. We are required to follow all the terms of this Notice. We reserve the right to change the provisions of this Notice and make it effective for all PHI we maintain. If you have any questions and/or would like additional information, you may contact our Privacy Officer at (205) 709-2970.

How We May Use and Disclose Your PHI. We may use and disclose your PHI in the following circumstances:

For Treatment. We may use or disclose your PHI to give you medical treatment or services and to manage and coordinate your medical care. For example, your PHI may be provided to a physician or other health care provider (e.g., a specialist or laboratory) to whom you have been referred to ensure that the physician or other health care provider has the necessary information to diagnose or treat you or provide you with a service.
For Payment. We may use and disclose your PHI so that we can bill for the treatment and services you receive from us and can collect payment from you, a health plan, or a third party. For example, we may need to give your health plan information about your treatment in order for your health plan to agree to pay for that treatment.
For Health Care Operations. We may use and disclose PHI for our health care operations. For example, we may use your PHI to internally review the quality of the treatment and services you receive and to evaluate the performance of our team members in caring for you. We also may disclose information to physicians, psychologists, counselors and other authorized personnel for educational and learning purposes.
Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services. We may use and disclose PHI to contact you to remind you that you have an appointment for medical care, or to contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you.
Minors. We may disclose the PHI of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law.
Research. We may use and disclose your PHI for research purposes, but we will only do that if the research has been specially approved by an authorized institutional review board or a privacy board that has reviewed the research proposal and has set up protocols to ensure the privacy of your PHI.
As Required by Law. We will disclose PHI about you when required to do so by international, federal, state, or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose PHI when necessary to prevent a serious threat to your health or safety or to the health or safety of others. But we will only disclose the information to someone who may be able to help prevent the threat.
Business Associates. We may disclose PHI to our business associates who perform functions on our behalf or provide us with services if the PHI is necessary for those functions or services. For example, we may use another company to do our billing, or to provide transcription or consulting services for us. All of our business associates are obligated, under contract with us, to protect the privacy and ensure the security of your PHI.
Military and Veterans. If you are a member of the armed forces, we may disclose PHI as required by military command authorities.
Workers’ Compensation. We may use or disclose PHI for workers’ compensation or similar programs that provide benefits for work- related injuries or illness.
Public Health Risks. We may disclose PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made in accordance with state law for the purpose of preventing or controlling disease, injury or disability.
Abuse, Neglect, or Domestic Violence. We may disclose PHI to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence and the patient agrees or we are required or authorized by law to make that disclosure.
Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure, and similar activities that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI in response to a court or administrative order. We also may disclose PHI in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get an order protecting the information requested. We may also use or disclose your PHI to defend ourselves in the event of a lawsuit.
Law Enforcement. We may disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes.
Military Activity and National Security. If you are involved with military, national security or intelligence activities or if you are in law enforcement custody, we may disclose your PHI to authorized officials so they may carry out their legal duties under the law.
Coroners, Medical Examiners, and Funeral Directors. We may disclose PHI to a coroner, medical examiner, or funeral director so that they can carry out their duties.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose PHI to the correctional institution or law enforcement official if the disclosure is necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.
Uses and Disclosures That Require Us to Give You an Opportunity to Object and Opt Out.

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.
Communications with Family and Others When you are Present. Sometimes a family member or other person involved in your care will be present when we are discussing your PHI with you. If you object, please tell us and we won’t discuss your PHI while that person is present.
Your Written Authorization is Required for Other Uses and Disclosures. We will obtain your written permission through an authorization for other uses and disclosures of your PHI not covered by this Notice. You may revoke the authorization in writing at any time and we will stop disclosing PHI about you for the reasons stated in your written authorization. Any disclosures made prior to the revocation are not affected by the revocation.

Your Rights Regarding Your PHI. You have the following rights, subject to certain limitations, regarding your PHI:

Right to Inspect and Copy. You may request, in writing, to inspect and obtain a copy of PHI about you that is contained in a “designated record set” for as long as we maintain the PHI. A “designated record set” contains medical and billing records and any other records about you that your physician and the practice uses for making decisions about you. We have up to 30 days to make your PHI available to you. You may request a summary of your PHI. We will make every effort to provide access to your PHI in the form or format that you request, if it is readily producible in such form or format. This right is subject to certain specific exceptions. If we deny your access to your PHI, we will provide you with a reason for the basis of the denial. In some instances, a right to have a decision to deny access can be reviewed. You may be charged a reasonable fee for any copies of your records as allowed by law. Contact our Privacy Officer if you have any questions about inspecting and copying your PHI.
Right to an Electronic Copy of Electronic Medical Records. If your PHI is maintained in an electronic format, you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your PHI in the form or format you request, if it is readily producible in such form or format. If the PHI is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.
Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured PHI.
Right to Request Amendments. If you feel that the PHI we have 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 or for us. A request for amendment must be made in writing to the Privacy Officer at the address provided at the end of this Notice and it must tell us the reason for your request. In certain cases, we may deny your request for an amendment. If we deny your request for an 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 copy of any such rebuttal.
Right to an Accounting of Disclosures. You have the right to ask for an “accounting of disclosures,” which is a list of the disclosures we made of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice. It excludes disclosures we may have made to you, for a resident directory, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions and limitations. Additionally, limitations are different for electronic health records. The first accounting of disclosures you request within any 12-month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting. We will tell what the costs are, and you may choose to withdraw or modify your request before the costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. To request a restriction on who may have access to your PHI, you must submit a written request to the Privacy Officer. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to your request, unless you are asking us to restrict the use and disclosure of your PHI to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we do agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment.
Out-of-Pocket-Payments. If you paid out-of-pocket in full for a specific item or service, you have the right to ask that your PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
Right to Request Confidential Communications. You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a specific address or call you only at your work number. You must make any such request in writing and you must specify how or where we are to contact you. We will accommodate all reasonable requests. We will not ask you the reason for your request.
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 may request a copy of this Notice at any time.
How to Exercise Your Rights. To exercise your rights described in this Notice, send your request, in writing, to our Privacy Officer at the address listed at the beginning of this Notice. We may ask you to fill out a form that we will supply. To exercise your right to inspect and copy your PHI, you may also contact your physician directly. To get a paper copy of this Notice, contact our Privacy Officer by phone or mail.

Changes To This Notice. We reserve the right to change this Notice. We reserve the right to make the changed Notice effective for PHI we already have as well as for any PHI we create or receive in the future. A copy of our current Notice is posted in our office and on our website.

Uses and Disclosures of Your Substance Abuse Records. The confidentiality of substance abuse records maintained by this practice is protected by another federal law commonly referred to as the Alcohol and Other Drug Confidentiality Law and its implementing regulations (42. C.F.R. Part 2). Generally, the program may not say to a person outside the program that a patient attends the program, or disclose information identifying a patient as an alcohol or drug abuser, unless: (i) the patient consents in writing; (ii) the disclosure is allowed by a court order; or (iii) the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. Violation of the Federal law and regulations by the Practice is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.

Complaints. You may file a complaint with us or with the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated. To file a complaint with us, contact our Privacy Officer at the address listed below. All complaints must be made in writing and should be submitted within 180 days of when you knew or should have known of the suspected violation. There will be no retaliation against you for filing a complaint. To file a complaint with the Secretary, mail it to: Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. Call (202) 619-0257 (or toll free (877) 696-6775) or go to the website of the Office for Civil Rights, www.hhs.gov/ocr/hipaa/, for more information. There will be no retaliation against you for filing a complaint.

Effective: May 31, 2022

IOP Services, LLC Attention: Privacy Officer

600 Century Park South Suite 200
Birmingham, AL 35226