Notice of Privacy Practices

Effective Date: 10.5.2026

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 questions about this Notice or need additional information, contact:

Privacy Officer
Connect Medical Clinic
683 State Avenue North, Suite E
Dickinson, ND 58601
Telephone: (701) 483-9353
Email: info@connectmedicalclinic.com

Receiving This Notice

You will receive this Notice no later than the date of your first service from Connect Medical Clinic. Except in an emergency treatment situation, we will make a good-faith effort to obtain your written or electronic acknowledgment that you received it. If we cannot obtain your acknowledgment, we will document our efforts and the reason it was not obtained, if known. Your refusal or inability to sign an acknowledgment will not prevent or delay your treatment.

In an emergency treatment situation, we will provide this Notice as soon as reasonably practicable after the emergency has ended. We are not required to obtain an acknowledgment following an emergency treatment situation.

When your first service is delivered electronically, including through telehealth, we will provide this Notice electronically, automatically and contemporaneously in response to your first request for service. You may request a paper copy at any time. The current Notice is also available at the clinic, through our website, and by QR code.

Our Responsibilities

We are required by law to:

• Maintain the privacy and security of your protected health information (PHI).
• Give you this Notice describing our legal duties and privacy practices concerning your PHI.
• Notify you following a breach of your unsecured PHI when notification is required by law.
• Follow the terms of the Notice currently in effect.

How We May Use and Disclose Your Health Information:

The following sections describe ways we may use or disclose your PHI without your written authorization. We will comply with all applicable legal requirements and limitations when making these uses or disclosures.

For Treatment. We may use and disclose your PHI to provide, coordinate, or manage your healthcare. For example, we may share relevant information with physicians, nurses, technicians, laboratories, pharmacies, or other healthcare professionals involved in your care.

For Payment. We may use and disclose your PHI to bill and obtain payment for services provided to you. For example, we may provide necessary information to your health plan to verify coverage, obtain prior authorization, or receive payment.

For Healthcare Operations. We may use and disclose your PHI for activities necessary to operate our clinic and improve the quality of care. For example, we may review patient records to evaluate provider performance, improve obstetrical or gynecological services, conduct compliance activities, train staff, or manage clinic operations. We may also share information with other entities that have a relationship with you when legally permitted for their healthcare operations.

For Appointment Reminders, Treatment Alternatives, and Health-Related Services. We may use your PHI to remind you about appointments and to provide information about treatment alternatives, care options, or health-related benefits and services that may interest you.

For Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share PHI directly relevant to a family member's, relative's, close friend's, or other person's involvement in your care or payment for your care. When possible, we will give you an opportunity to agree or object. If you are unable to agree or object, we may share information when, in our professional judgment, doing so is in your best interest.

For Disaster Relief. We may share appropriate information with an organization assisting in disaster-relief efforts so that your family or others responsible for your care can be notified of your location, general condition, or death. When practicable, we will give you an opportunity to agree or object.

For Business Associates. We may disclose PHI to business associates that perform services for us, such as billing or information-technology services. Business associates are required by law and written agreement to appropriately safeguard the information and use or disclose it only as permitted.

For Fundraising. We may use certain limited PHI to contact you about fundraising for Connect Medical Clinic. You have the right to opt out of receiving fundraising communications. Your decision will not affect your treatment or payment for services.

How we are Required by Law: We will disclose your PHI when federal, state, or local law requires us to do so:

For Public Health and Safety. We may disclose PHI for legally authorized public-health activities, including preventing or controlling disease, reporting births or deaths, reporting certain communicable conditions, reporting adverse reactions or product problems, assisting with product recalls, and notifying individuals who may have been exposed to or be at risk of spreading a disease. We may use or disclose PHI when necessary to prevent or lessen a serious and imminent threat to a person's or the public's health or safety. Such disclosures will be made only to a person reasonably able to prevent or lessen the threat.

For Reporting Abuse, Neglect, or Domestic Violence. We may disclose PHI to an authorized government agency concerning suspected abuse, neglect, or domestic violence when the disclosure is required or permitted by law. When applicable, we will inform you of the disclosure unless doing so would place you or another person at risk of serious harm.

For Health Oversight Activities. We may disclose PHI to health-oversight agencies for activities authorized by law, including audits, investigations, inspections, credentialing, licensure, disciplinary actions, and civil-rights compliance.

For Judicial and Administrative Proceedings. We may disclose PHI in response to a court or administrative order. We may also disclose PHI in response to a subpoena, discovery request, or other lawful process when all applicable legal requirements have been met.

For Law Enforcement. We may disclose PHI to law-enforcement officials as permitted or required by law, including in response to certain court orders, warrants, subpoenas, or other legal processes; to identify or locate certain persons; concerning certain crime victims; concerning a death suspected to have resulted from criminal conduct; concerning criminal conduct on our premises; or to report limited information about a crime during an emergency.

For Coroners, Medical Examiners, and Funeral Directors. We may disclose PHI to coroners, medical examiners, and funeral directors as necessary for them to perform duties authorized by law. HIPAA protection of a deceased person's health information generally continues for 50 years after death.

For Organ and Tissue Donation. If you are an organ donor, we may disclose PHI to organ-procurement organizations or other entities involved in procuring, banking, or transplanting organs, eyes, or tissue.

For Workers' Compensation. We may disclose PHI as authorized by and to the extent necessary to comply with workers' compensation or similar programs that provide benefits for work-related injuries or illnesses.

For Military and Veterans. If you are or were a member of the armed forces, we may disclose PHI as required by military-command authorities or other applicable law. We may also disclose information concerning foreign military personnel to the appropriate foreign military authority as permitted by law.

For National Security and Protective Services. We may disclose PHI to authorized federal officials for lawful intelligence, counterintelligence, national-security, and protective-service activities.

For Correctional Institutions and Law-Enforcement Custody. If you are an inmate or in lawful custody, we may disclose PHI to the correctional institution or law-enforcement official when necessary to provide healthcare, protect your health or safety or that of others, or maintain the safety and security of the institution.

For Research. We may use or disclose PHI for research when the research has been approved through a process that evaluates the privacy protections of the study or when another legal permission or exception applies.

For Incidental Uses and Disclosures. Limited incidental uses or disclosures may occur as a by-product of an otherwise permitted use or disclosure. We use reasonable safeguards and apply the minimum-necessary standard when required to limit incidental disclosures.

For Breach Notification. We may use or disclose PHI as necessary to provide notifications required following unauthorized access to or disclosure of health information.

Uses and Disclosures Requiring Your Written Authorization:

The following uses and disclosures generally require your written authorization:

1. Most uses and disclosures of psychotherapy notes, when applicable;
2. Uses and disclosures of PHI for marketing purposes, except as otherwise permitted by law; and
3. Disclosures that constitute a sale of your PHI.

Other uses and disclosures not described in this Notice will be made only with your written authorization. If you authorize a use or disclosure, you may revoke that authorization at any time by submitting a written revocation to the Privacy Officer. Your revocation will not affect any action we already took in reliance on your authorization.

Your Rights

You have the following rights regarding the PHI we maintain about you;

Inspect and Obtain a Copy. You have the right to inspect and obtain a copy of the protected health information (PHI) maintained in your designated record set, including most medical and billing records. You may request the copy in either paper or electronic form. Psychotherapy notes and certain other information may be excluded as required by law. Requests must be submitted in writing to Connect Medical Clinic, and we will respond within the legally-required time frame. If we maintain your PHI electronically, we will provide it in the electronic form and format you request when it is readily producible. You may also ask us to transmit a copy to another person or entity when applicable legal requirements are met. We will not charge a fee for routine patient requests for copies of your own records; however, for large-volume requests requiring mailing, we may charge reasonable, cost-based postage when permitted by law. We will notify you in advance of any applicable fee. We may deny access in limited circumstances. If the denial is reviewable, you may request a review by a licensed healthcare professional who was not involved in the original decision, and we will comply with the outcome of that review.

Request an Amendment. If you believe that PHI we maintain about you is incorrect or incomplete, you may request an amendment for as long as we maintain the information. Submit your request in writing to Connect Medical Clinic and explain why the information should be amended. We may deny the request in certain circumstances, but we will provide a written explanation and information about your additional rights.

Request an Accounting of Disclosures. You may request a list of certain disclosures we made of your PHI during the period permitted by law. An accounting does not include every disclosure, such as most disclosures for treatment, payment, or healthcare operations or disclosures you authorized. Submit your request in writing to Connect Medical Clinic.

Request Restrictions. You may request that we limit certain uses or disclosures of your PHI for treatment, payment, or healthcare operations, or limit information shared with someone involved in your care or payment for your care. We generally are not required to agree to a requested restriction.

We must agree to your request not to disclose information to a health plan when the disclosure would be for payment or healthcare operations, is not otherwise required by law, and the information relates solely to an item or service for which you or another person paid Connect Medical Clinic in full out of pocket. Submit restriction requests in writing to Connect Medical Clinic.

Request Confidential Communications. You may ask us to contact you in a particular way or at a particular location. For example, you may ask us to contact you only at a specified telephone number or address. Submit your request in writing and identify how or where you want to be contacted. We will accommodate reasonable requests.

Receive Notice of a Breach. You have the right to receive notification following a breach of your unsecured PHI when notification is required by law.

Obtain a Paper Copy of This Notice. You may request a paper copy of this Notice at any time, even if you previously agreed to receive it electronically.

To opt out of the Electronic Health Information Network. You may request to opt out of Health Information at anytime.

File a Privacy Complaint. If you believe your privacy rights have been violated, you may file a complaint with Connect Medical Clinic by contacting the Privacy Officer using the contact information at the beginning of this Notice. We will provide reasonable assistance if you need help submitting a complaint.

You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services through the HHS Office for Civil Rights at https://www.hhs.gov/ocr/privacy/hipaa/complaints/, by calling 1-877-696-6775, or by writing to:

U.S. Department of Health and Human Services
200 Independence Avenue SW
Washington, DC 20201

Connect Medical Clinic will not intimidate, threaten, coerce, discriminate against, or retaliate against you for exercising a privacy right or filing a complaint. Filing a complaint will not affect your care or services.

Changes to This Notice

We reserve the right to change this Notice and our privacy practices. When permitted by law, a revised Notice may apply to PHI we already maintain as well as information we receive in the future.

When a material change is made, we will issue a revised Notice with a new effective date. The current Notice will be posted in full in a clear and prominent location at our clinic, posted on our website, available through our QR code, and provided to any person upon request. You will not be required to sign a new acknowledgment solely because the Notice has been revised.

Reviewed 10.05.2026