HIPAA NOTICE OF PRIVACY PRACTICES

(Effective June 5, 2023)
At Vitally Doc, LLC, we understand that health information about you is very personal and we are
mandated by the Health Insurance Portability and Accountability Act (“HIPAA”) to protect your
health information. We create a record of the care and services you receive from us, and this record
helps to provide you with quality care and to comply with certain legal requirements. This Notice
applies to all of the records of your care generated by us, and informs you about the ways in which
we may use and disclose information about you. We also describe your rights to the health
information we keep about you, and describe certain obligations we have regarding the use and
disclosure of your health information.
Vitally Doc, LLC will take every reasonable action to protect your health care information

including the protection of your verbal, written, and electronic protected health information (“e-
PHI”) using all means necessary while ensuring that the information is readily available to the

providers that deliver your health care. “Protected health information” is information about you,
including demographic information, that may identify you and that relates to your past, present or
future physical or mental health or condition and related health care services. Vitally Doc, LLC
implements appropriate administrative, technical, and physical safeguards to protect your health
information across the company from unintended or unauthorized use, disclosure, modification or
loss.
Uses and Disclosures of Protected Health Information for Treatment: Your PHI may be used
and disclosed by Vitally Doc, LLC staff and others outside of our offices that are involved in the
delivery of health care services and benefits. Your protected health information may also be used
and disclosed to pay your health care bills and to support Vitally Doc, LLC operations.
Following are examples of the types of uses and disclosures of your protected health care
information that we are permitted to make. These examples are not meant to be exhaustive, but to
describe the types of uses and disclosures that may be made.

• Treatment
• Health Care Operations
• Appointment Reminders
• Uses and Disclosures of PHI based on your written authorization
• Required by law
• Health Oversight
• Legal Proceedings
• Public Health Activities
• Abuse or Neglect
• Law Enforcement
• Communicable Diseases
• FDA Regulations
• Research
• Others Involved in Your Health Care

Your Rights Regarding Health Information About You: Following are your rights with respect
to your protected health information. You may exercise any of these rights by contacting us as
described at the end of this Notice.
 The right to inspect and/or copy your protected health information.
 The right to request a restriction of your protected health information.
 The right to restrict release of information for certain services.

HIPAA NOTICE OF PRIVACY PRACTICES

The right to request and receive confidential communications.
The right to have Vitally Doc, LLC amend your PHI.
The right to receive accounting of certain disclosures we have made, if any of your PHI.
The right to a breach notification.
The right to obtain a paper copy of this notice from us.

 Make sure that health information that identifies you is kept private.
 Give you this Notice of our legal duties and privacy practices with respect to health
information about you.
 Follow the terms of the Notice that is currently in effect.
Your Medical Records: The original copy of your and/or electronic medical record is the property
of Vitally Doc, LLC You may request a copy of your records to be transferred by completing a
medical records release form. As allowed by Florida state law, there will be a fee for providing
you with this service. We require 14 business days from the date of your request to prepare and
send your records unless the records are for urgent of life-threatening health issues.
Changes to this Notice: We reserve the right to change this Notice. We will post a copy of the
current notice in our facility with the current effective date.
Complaints: If you have a question about this Notice, or you wish to exercise your rights
described in this Notice, or you believe your privacy rights have been violated, you may contact
us at: Vitally Doc Integrative Medicine, LLC – 4755 Summerlin Road Suite 2, Fort Myers , FL 33919.
For complete, detailed information regarding privacy laws, visit www.cms.gov/hipaa. All
complaints must be submitted in writing. You will not be penalized for filing a complaint. A
complaint may also be filed with the U.S. Department of Health and Human Services.
Permission to Share your Health Information: We are required to follow certain federal
guidelines and laws regarding the confidentiality of your personal health information. One of these
prevents us from discussing anything in your medical file with anyone other than yourself or other
medical personnel involved in your care. If you would like us to discuss personal information with
your significant other, family members, or any other individuals, please fill in their name and
relationship to you in the section listed below.