NOTICE OF PRIVACY PRACTICES
Effective Date: July 2026
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.
If you have any questions about this notice, please contact us using the contact information listed at the end of this document.
Our Pledge Regarding Medical Information
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive 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 this medical practice.
1. Permitted Uses and Disclosures of Protected Health Information (PHI)
We may use and disclose your PHI for the following purposes without your explicit written authorization:
- For Treatment: We may use and disclose your PHI to provide, coordinate, or manage your healthcare treatment. For example, we may disclose medical information to a specialist we refer you to, or to a pharmacist to fill a prescription.
- For Payment: We may use and disclose your PHI 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 send information to your health insurance plan to get paid for an office visit.
- For Healthcare Operations: We may use and disclose your PHI to run our practice and ensure all patients receive quality care. For example, we may use PHI to review our treatment and services, or to evaluate the performance of our staff.
- As Required by Law: We will disclose PHI when required to do so by federal, state, or local law.
- Public Health Risks: We may disclose PHI for public health activities, such as preventing or controlling disease, injury, or disability, or reporting child abuse or neglect.
- Law Enforcement & Legal Proceedings: We may disclose PHI in response to a court order, subpoena, warrant, summons, or similar process, or for law enforcement purposes.
- 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 and safety or the health and safety of the public or another person.
2. Uses and Disclosures Requiring Your Written Authorization
Other uses and disclosures not covered by this notice will be made only with your written authorization. You may revoke this authorization at any time in writing.
- Psychotherapy Notes: Most uses and disclosures of psychotherapy notes require your authorization.
- Marketing: We will not use or disclose your PHI for marketing purposes without your authorization.
- Sale of PHI: We will not sell your PHI without your authorization.
3. Your Rights Regarding Your PHI
You have the following rights regarding the medical information we maintain about you:
- Right to Inspect and Copy: You have the right to inspect and receive a copy of your health and billing records. This includes electronic records if maintained digitally. You must submit your request in writing. We may charge a reasonable, cost-based fee for copying and mailing.
- Right to Request an Amendment: If you feel that medical 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 our practice. Your request must be made in writing and provide a reason supporting your request.
- Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we made of your PHI for purposes other than treatment, payment, or healthcare operations. Your request must state a time period, which may not be longer than six years.
- Right to Request Restrictions: You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the PHI we disclose to someone involved in your care, like a family member. Note: We are not required to agree to your request, unless you request that we not disclose PHI to a health plan for payment or operations purposes, and the PHI pertains solely to a healthcare item or service for which you have paid out-of-pocket in full.
- Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. We will accommodate all reasonable requests.
- Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice at any time, even if you have agreed to receive this notice electronically.
4. Breach Notification
We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices. In the event of a breach of your unsecured PHI, we will notify you as required by federal law.
5. Complaint Procedures
If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. You will not be penalized or retaliated against for filing a complaint.
To file a complaint with our practice, submit your complaint in writing to us using the contact information below.
6. Contact Information
If you have any questions, wish to exercise any of your rights listed above, or need to file a complaint, please contact us:
- Practice Name: REVIVE MEDICAL WEIGHT LOSS CENTERS LLC
- Mailing Address: 2855 W Market St 108, Fairlawn, OH 44333
- Email Address: info@reviveweightlosscenters.com
- Phone Number: (234) 219-2659
7. Changes to This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice on our website and in our facility.