(Effective Date of 11/20/2021) As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA),

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A CLIENT OR REPRESENTATIVE OF THIS SERVICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.

Please review this notice carefully. (Revision Date 12/10/2024)

Our commitment to your privacy

BlueSprig Pediatrics, Inc. is dedicated to maintaining the privacy of your protected health information (PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time of your care.

We realize that these laws are complicated, but we must provide you with the following important information:

• How we may use and disclose your PHI
• Your privacy rights regarding your PHI
• Our obligations concerning the use and disclosure of your PHI

The terms of this notice apply to all records containing your PHI that are created or retained by BlueSprig Pediatrics. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. BlueSprig will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

You have the right to:

• Receive a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Receive a list of those with whom we have shared your information
• Receive a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

We may use and share your information as we:

• Provide you services
• Run our organization
• Bill for services we provided
• Help with public health and safety issues
• Do research
• Comply with the law
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

You have some choices in the way that we use and share information as we:

• Tell family and friends about your outcomes
• Provide disaster relief
• Provide mental health care
• Market our services and sell your information

File a complaint if you feel your rights are violated:

• You can complain if you feel we have violated your rights by contacting BlueSprig at (833) 227-0693.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending written communication to:

Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201

Or filing a form through the portal located at:

https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf

• We will not retaliate against you for filing a complaint.