LifeSource Wellness Care Statement of Privacy Practices

We reserve the right to change our privacy practices and terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make significant change in our privacy practices we will update this notice and make the new notice available upon request. You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact our office.

USES AND DISCLOSURES OF HEALTH INFORMATION:We use and disclose health information about you for the following reasons:

TREATMENT: We may use or disclose you health information to other healthcare personnel providing treatment to you.

YOUR AUTHORIZATION: In addition to our use of your health information for treatment, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give written authorization, we cannot use or disclose your health information for any reason except those described in this notice.

YOUR FAMILY AND FRIENDS: We must disclose your health information to you, as described in the patient’s rights section of this notice. We may disclose your health information to family member, friend or other person to the extent necessary to help with your healthcare, but only if you agree to do so.

PERSONS INVOLVED WITH YOUR CARE: We may use or disclose your health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition or death. If you are present, then prior to use or disclosure of your health information, we will provide you with the opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

REQUIRED BY LAW: We will use or disclose your health information when we are required to do so by law.

ABUSE OR NEGLECT: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

NATIONAL SECURITY: We may disclose to military authorities the health information of armed forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.

APPOINTMENT REMINDERS: We may use or disclose your health information to provide you with appointment reminders i.e.: voicemail messages, or letters.

PATIENT RIGHTS:

ACCESS: You have the right to look at or get copies of your health information with, limited exception. The request for your health information must be requested in writing. A fee of 15 cents per page and $15.00 per hour staff time will be assessed. If your request is to mail your records, postage will be added to the other costs. A formal report written by Dr. Thermos must be requested by you in writing and the fee will be $100.00 per hour.

DISCLOSURE ACCOUNTING: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, healthcare, operations and certain other activities since April 14, 2003.

RESTRICTIONS: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency.)

ALTERNATIVE COMMUNICATION: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. This request must be made in writing. Your request must specify the alternative means or location.

AMENDMENT: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. Your request may be denied in certain circumstances. Should you have any complaints regarding our privacy policies, you have the right to complain to us through our office. If you feel we have violated your privacy rights or denied you any of the patient’s rights which you feel you are entitled, you may submit your complaint to the U.S. Department of Health and Human services.

LIFESOURCE WELLNESS CARE / DR ALEXANDER THERMOS, DC, DO

27001 La Paz Rd, Suite 294

Mission Viejo, CA 92691

949-973-0577