Alpha Medical Consents and Notices
Notice of Privacy Practices

Who We Are
This Notice describes the privacy practices of Alpha Telemedicine, P.C., Alpha Telemedicine of Kansas, P.A., Alpha Telemedicine of New Jersey, P.A., Alpha Telemedicine of Alaska, P.C. all of which provide healthcare services via telehealth or telemedicine (referred to in this Notice as “we” or “us”).

Purpose and Scope
We respect your privacy. We are also legally required to maintain the privacy of your protected health information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA) and other federal and state laws. We follow state privacy laws when they are stricter or more protective of your PHI than federal law.
We create a record of the care and health services you receive, to provide your care, and to comply with certain legal requirements. This Notice applies to all the PHI that we generate.
We follow, and our employees and other workforce members follow, the duties and privacy practices that this Notice describes and any changes once they take effect.
The law permits or requires us to use or disclose your PHI for various reasons, which we explain in this Notice. We have included some examples, but we have not listed every permissible use or disclosure. When using or disclosing PHI or requesting your PHI from another source, we will make reasonable efforts to limit our use, disclosure, or request about your PHI to the minimum we need to accomplish our intended purpose.
As part of our commitment and legal compliance, we are providing you with this Notice of Privacy Practices (Notice). This Notice describes:

• Our legal duties and privacy practices regarding your PHI, including our duty to notify you following a data breach of your unsecured PHI.
• Our permitted uses and disclosures of your PHI.
• Your rights regarding your PHI.

PHI Defined
Your PHI is health information about you which someone may use to identify you and which we keep or transmit in electronic, oral, or written form. It includes information such as your:
• name;
• contact information;
• past, present, or future physical or mental health or medical conditions;
• payment for health care products or services; or
• prescriptions.

PHI does not include employment records that your employer may hold.

Uses and Disclosures for Treatment, Payment, or Health Care Operations
• Treatment. We may use or disclose your PHI and share it with other professionals who are treating you, including doctors, nurses, technicians, medical students, or hospital personnel involved in your care. For example, we might disclose information about your overall health condition to physicians who are treating you for a specific injury or condition. We may also recommend alternative treatments, refer you to other providers, or otherwise communicate with other providers involved in your care or treatment.
Payment. We may use and disclose your PHI to bill and get payment from you, from health plans or others. For example, we share your PHI with your health insurance plan so it will pay for the services you receive or to assist you with requesting insurance payment for prescriptions.
Health Care Operations. We may use and disclose your PHI to run our practice and improve your care. For example, we may use your PHI to manage the services you receive or to monitor the quality of our health care services, or to evaluate the quality and competence of providers and improve our care. We may also disclose PHI to personnel of our Business Associates as necessary to improve our support to you, resolve any concerns or complaints to you may have, ensure you are satisfied with our services, and otherwise communicate with you about our services or market our services to you.

Other Uses and Disclosures
We may share your information in other ways, usually for health or research purposes or to contribute to the public good. For more information on permitted uses and disclosures, see For example, these other uses and disclosures may involve:
Our Business Associates. We may use and disclose your PHI to outside persons or entities that perform services on our behalf, such as, but not limited to, auditing, legal, platform support, or transcription (Business Associates). The law requires our business associates and their subcontractors to protect your PHI in the same way we do. We also contractually require these parties to use and disclose your PHI only as permitted and to appropriately safeguard your PHI.
Legal Compliance. For example, we will share your PHI if the Department of Health and Human Services requires it when investigating our compliance with privacy laws.
Public Health and Safety Activities. For example, we may share your PHI to report injuries, births, and deaths; prevent or respond to the spread of disease; report adverse reactions to medications or medical device product defects; report suspected child neglect or abuse, or domestic violence; report information about products under the jurisdiction of the U.S. Food and Drug Administration, or avert a serious threat to public health or safety.
• Responding to Legal Actions. For example, we may share your PHI to respond to:
o a court or administrative order or subpoena;
o discovery request; or
o another lawful process.
• Research. For example, we may share your PHI for some types of health research that do not require your authorization, such as if an institutional review board (IRB) has waived the written authorization requirement because the disclosure only involves minimal privacy risks. In addition, under certain circumstances, portions of your PHI may be disclosed without your authorization to researchers preparing to conduct a research project, for research or decedents or as part of a data set that omits your name and other information that can directly identify you.
Medical Examiners or Funeral Directors. For example, we may share PHI with coroners, medical examiners, or funeral directors when an individual dies.
• Organ and Tissue Procurement. We may disclose your PHI to organizations that facilitate organ or tissue procurement, banking or transplantation.
Workers' Compensation, Law Enforcement, or Other Government Requests. For example, we may use and disclose your PHI for:
o workers' compensation claims;
o health oversight activities by federal or state agencies;
o law enforcement purposes or with a law enforcement official; or
o specialized government functions, such as military and veterans' activities, national security and intelligence, presidential protective services, or medical suitability.
• We may also fulfill your request that we communicate your PHI to a third party based on your written authorization.

Your Choices
You have some choices about how we use and share information as we:
• Communicate with you.
• Tell family and friends about your condition.
• Provide disaster relief.
• Provide mental health care.
• Market our services.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, please contact us at and we will make reasonable efforts to follow your instructions.

You have both the right and choice to tell us whether to:
• Share information, such as your PHI, general condition, or location, with your family, close friends, or others involved in your care.
• Share information in a disaster relief situation, such as to a relief organization to assist with locating or notifying your family, close friends, or others involved in your care.

We may share your information if we believe it is in your best interest, according to our best judgment, and:
• If you are unable to tell us your preference, for example, if you are unconscious.
• When needed to lessen a serious and imminent threat to health or safety.

Uses and Disclosures that Require Authorization
In these cases, we will only share your information if you give us written permission:
• Most sharing of a mental health care professional's notes (psychotherapy notes) from a private counseling session or a group, joint, or family counseling session, or alcohol and drug abuse treatment records.
• Marketing our services, which permission you give us through your Consent to Telehealth. You can change your preferences at any time by contacting us. In addition, we follow certain limitations designed to protect your privacy. For example, we will not sell your information to third parties or accept payments from third parties in exchange for making communications to you about those third parties’ products or services unless you have given us your authorization to do so or the communication is permitted by law. We may provide refill reminders or communicate with you about a drug or biologic that is currently prescribed to you, or we may communicate with you on behalf of your employer to describe our services available to you, but in such case, any payment we receive solely for making the communication is reasonably related to our cost of making the communication. In addition, we may ask you to rate our services or provide feedback, and we may give you promotional gifts of nominal value without obtaining your written authorization.
• Selling or otherwise receiving compensation for disclosing your PHI.
• Other uses and disclosures not described in this Notice.

You may revoke your authorization at any time, but it will not affect information that we already used and disclosed.

Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
You have the right to:
Inspect and Obtain a Copy of Your PHI. You have the right to see or obtain an electronic or paper copy of the PHI that we maintain about you (right to request access). Alternatively, you may request a summary of your PHI or an explanation of your PHI. Some clarifications about your access rights:
o We require you to make access requests in writing to the address at the top of this notice.
o We may charge a reasonable, cost-based fee for the costs of copying, mailing, or other supplies associated with your request.
o You may request that we provide a copy of your PHI to a family member, another person, or a designated entity. We require that you submit these requests in writing to the address at the top of this notice.
o You may request that we direct a copy of your PHI to a third party of your choice on a standing, regular basis. We require that you submit these requests in writing to the address at the top of this notice.
o If you request a copy of your PHI, we will generally decide to provide or deny access within 30 days, however, if we cannot act within 30 days, we will give you a reason for the delay in writing and when you can expect us to act on your request.
o We may deny your request for access in certain limited circumstances, however, if we deny your access request, we will provide a written denial with the basis for our decision and explain your rights to appeal or file a complaint.

• Make Amendments. You may ask us to correct or amend PHI that we maintain about you that you think is incorrect or inaccurate. For these requests:
o You must submit requests in writing to the address at the top of this notice, specify the inaccurate or incorrect PHI, and provide a reason that supports your request.
o We will generally decide to grant or deny your request within 60 days. If we cannot act within 60 days, we will give you a reason for the delay in writing and include when you can expect us to complete our decision, which will be no longer than an additional 30 days. We will only ask for an extension once in response to a request.
o We may deny your request for an amendment if you ask us to amend PHI that is not part of our record, that we did not create, that is not part of a designated record set, or that is accurate and complete.
o If we deny your request, we will tell you why in writing. You will have the right to submit a written statement disagreeing with the denial and, if you opt not to submit this statement, you may request that we provide your original request for amendment and the denial with any future disclosures of PHI subject to the amendment. However, we may prepare a written rebuttal to any individual's statement of disagreement.
o We will append the material created or submitted in accordance with this paragraph to your designated record.

• Request Additional Restrictions. You have the right to ask us to limit what we use or share about your PHI (right to request restrictions). You can contact us and request us not to use or share certain PHI for treatment, payment, or operations or with certain persons involved in your care. We require that you submit this request in writing to the address at the top of this notice. For these requests:
o we are not required to agree;
o we may say "no" if it would affect your care; but
o we will agree not to disclose information to a health plan for purposes of payment or health care operations if the requested restriction concerns a health care item or service for which you or another person, other than the health plan, paid in full out-of-pocket, unless it is otherwise required by law.

Request an Accounting of Disclosures. You have the right to request an accounting of certain PHI disclosures that we have made. For these requests:
o We will respond no later than 60 days after receiving the request. We may ask for an additional 30 days during this 60-day period, but if we do, we will only do it once, provide a written statement of why, and indicate the date by which we intend to send the response.
o We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures, such as any you asked us to make; and
o We will provide one accounting a year for free, but will charge a reasonable, cost-based fee if you ask for another one within 12 months. We will notify you about the costs in advance and you may choose to withdraw or modify your request at that time.

• Choose Someone to Act for You. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your PHI.

• Confidential Communications. Our secure platform allows you to select where you view messages about health matters and in what location. We ask you to use this platform alone and to keep your password safe and do not share it with others.

• Make Complaints. You have the right to complain if you feel we have violated your rights. We will not retaliate against you for filing a complaint. You may either file a complaint:
• directly with us by contacting our Privacy Officer at the address at the top of this Notice. All complaints must be submitted in writing; or
• with the Office for Civil Rights at the US Department of Health and Human Services. Send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201 or call 877-696-6775; or visit

If you have any questions about this Notice, please contact Our mailing address is below:

555 Bryant Street, Suite 814
Palo Alto, CA 94301-1704
Privacy Officer: Mary Therese Jacobson, M.D.

Changes to this Notice
We can change the terms of this Notice, and the changes will apply to all information we have about you. The new notice will be available on request, in our office, and on our website.

Data Breach Notification
We will promptly notify you if a data breach occurs that may have compromised the privacy or security of your PHI. We will notify you within the legally required time frame, no later than 60 days after we discover the breach. Most of the time, we will notify you in writing, by first-class mail, or we may email you if you have provided us with your current email address and you have previously agreed to receive notices electronically. In some circumstances, our business associates, which are described in more detail below, may provide the notification. In limited circumstances when we have insufficient or out-of-date contact information, we may provide notice in a legally acceptable alternative form.