NOTICE OF PRIVACY PRACTICE

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.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other individually identifiable health information used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

Patient Authorization for Marketing Communications

I authorize Advanced Women’s Health of NJ to disclose my name, phone number, and email address to its contracted marketing and communication partners for the purpose of sending me information about services, educational content, events, and promotional offerings.

I understand and acknowledge that:

• This authorization is voluntary and not a condition of receiving treatment, payment, enrollment, or eligibility for benefits
• My information may be used to contact me via phone calls, text messages, and/or email communications
• My information will not be used for any purpose other than the marketing and communication activities described above
• I may revoke this authorization at any time by submitting a written request to [Practice Contact Info], and such revocation will not affect any prior disclosures made in reliance on this authorization

By signing below or selecting this option, I acknowledge that I have read and understand this authorization.

In addition, your confidential information may be used to remind you of an appointment (by phone or mail) or provide you with information about treatment alternatives or other health related services. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. SMS opt-in and phone numbers collected for SMS purposes will not be shared with third parties or affiliates for marketing purposes.

I agree to receive recurring automated marketing and informational messages from Advanced Women’s Health of NJ . Message and data rates may apply. Message frequency varies. I understand I can opt out at any time by replying STOP or contacting the practice directly

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of April 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. Revisions to our Notice of Privacy Practices will be posted on the effective date and you may request a written copy of the revised notice from this office.

If you believe your privacy rights have been violated, you may file a complaint with the practice or with the Secretary of the Department of Health and Human Services. All complaints must be made in writing.