Telehealth Consent Form

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TERMS OF SERVICE

AMONG OTHER ACTIVITIES, M&D INTEGRATIONS INC.’S SERVICES ENABLE COORDINATION AND COMMUNICATION WITH A HEALTH CARE PROVIDER. IT DOES NOT REPLACE YOUR RELATIONSHIP WITH ANY PHYSICIAN. THESE SERVICES MIGHT NOT BE APPROPRIATE FOR ALL MEDICAL CONDITIONS OR CONCERNS. IF YOU HAVE A MEDICAL EMERGENCY, IMMEDIATELY CALL YOUR DOCTOR OR DIAL 911.

PLEASE READ THESE TERMS AND CONDITIONS CAREFULLY BECAUSE THEY SET FORTH THE IMPORTANT TERMS YOU WILL NEED TO KNOW ABOUT THE SERVICES.

YOU UNDERSTAND THAT BY ACCESSING OR USING THE SITES OR SERVICES, YOU ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD, AND AGREED TO BE LEGALLY BOUND BY AND COMPLY WITH THESE TERMS OF USE. IF YOU DO NOT OR CANNOT AGREE WITH ANY PART OF THESE TERMS OF USE, YOU MAY NOT USE THE SITES OR ANY SERVICES PROVIDED ON OR THROUGH THE SITES.

THE TERMS OF USE ARE SUBJECT TO CHANGE AS PROVIDED HEREIN.

INTRODUCTION

M&D Integrations, Inc. (collectively, “M&D Integrations,” “we”, “us”, or “our”) own and operate the websites located at www.mdintegrations.com. The Sites are intended to facilitate the provision of the Services to registered users. The “Services” may include (i) providing individuals with information on health care and wellness (“Content”); (ii) providing individuals with access to technology-oriented tools for acne treatment; (iii) development and gathering of health care records and health care information with retention of the same for use in health care provider appointments, and communications; (iv) administrative support in connection with scheduling, and payment for health care provider services; and (v) telecommunications support for using the Services as a means of direct access to health care providers provided by M&D Integrations and similar affiliated professional entities for communication, consultations, assessments, and treatment by such health care organizations and their providers.

These terms and conditions of use (“Terms of Use”) describe your rights and responsibilities with regard to the M&D Integrations Sites that you may use to receive Services. Your access to and use of the Sites is subject to these Terms of Use, our Privacy Policy, as well as all applicable laws and regulations. In these Terms of Use, the terms “you” and “yours” refer to the person using the Services. Even though you may have arrived to the Sites through a website or mobile application operated or controlled by a third party, you understand and agree that these Terms of Use are entered into between you and M&D Integrations. If you do not accept and agree to be bound by these Terms of Use, you are not authorized to access or otherwise use the Sites, Services or any information or Content provided through the Sites or Services. The Sites and Services are continually under development, and M&D Integrations reserves the right to review or remove any part of these Terms of Use in its sole discretion at any time and without prior notice to you. Any changes to these Terms of Use are effective upon posting to the Sites.

Unless otherwise indicated, any new Content added to the Services is also subject to these Terms of Use upon posting to the Sites. If you disagree with these Terms of Use, your sole and exclusive remedy is to discontinue your use of the Sites and/or Services. Your continued use after a change has been posted constitutes your acceptance of the changes.

AVAILABILITY

Certain of our Services are currently only available to individuals located in certain states. (See List of States.)

ELIGIBILITY

In order to qualify to use the Services, the following must be true:

  • You are age 18 years or over or are accompanied by your parent/guardian.
  • You are located in a State Where We Operate.
  • You agree to be legally bound by and comply with these Terms of Use. You understand and agree that satisfying the above requirements does not guarantee that you will receive Services through M&D Integrations. In addition to the above requirements, M&D Integrations and certain affiliated professional entities reserve the right to change or include new requirements as deemed appropriate in their sole discretion without providing prior notice to you.

REQUIREMENTS FOR USE

You must have compatible computing and/or mobile devices, access to the Internet, and certain necessary software in order to use the Sites.

FULFILLMENT

Medical consultations and messages will be reviewed within 24 hours of submission.

SPECIAL CONSENT TO TELEHEALTH SERVICES

Telemedicine involves the delivery of health care services using electronic communications, information technology, or other means between a health care provider and a patient who are not in the same physical location. Telemedicine may be used for diagnosis, treatment, follow-up and/or related patient education, and may include, but is not limited to:

  • Electronic transmission of medical records, photo images, personal health information, or other data between a patient and health care provider;
  • Interactions between a patient and health care provider via audio, video, and/or data communications; and
  • Use of output data from medical devices, sound, and video files.

The electronic systems used in the Services will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.

CALIFORNIA NOTICE TO CONSUMERS

Medical doctors are licensed and regulated by the Medical Board of California.

(800) 633-2322

www.mbc.ca.gov/

Complaints may be filed online at http://www.mbc.ca.gov/

Breeze/Complaints.aspx or submitted in hard copy form. A Consumer Complaint Form, including instructions for completing it, may be found at http://www.mbc.ca.gov/

Consumers/Complaints/

Submit_By_Mail.aspx. A hard copy Consumer Complaint Form should be submitted to:

Medical Board of California

Central Complaint Unit

2005 Evergreen Street, Suite 1200

Sacramento, CA 95815

The Central Complaint Unit of the Medical Board of California can be contacted by phone at 1-800-633-2322 or 916-263-2382.

KANSAS

It is unlawful for any person who is not licensed under the Kansas Healing Arts Act to open or maintain an office for the practice of the healing arts in this State.

This office is maintained under the authority of a person who is licensed to practice the healing arts of Kansas.

Questions and concerns regarding this professional practice may be directed to:

Kansas State Board Of Healing Arts

800 SW Jackson, Lower Level-Suite A

Topeka, Kansas 66612

Phone: (785) 296-7413

Toll Free: 1(888) 886-7205

Fax: (785) 296-0852

Website: www.ksbha.org

OREGON

Complaints about physicians, as well as other licensees and registrants of the Oregon Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation to:

Oregon Medical Board

Investigations Manager

1500 SW 1st Ave. #620

Portland, OR 97201

P: (971) 673-2702

Toll Free: 1(877) 254-6263

https://www.oregon.gov/omb/investigations/pages/how-to-file-a-complaint.aspx

TEXAS

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation to:

Texas Medical Board

Attention: Investigators

333 Guadalupe, Tower 3, Suite 610

P.O Box 2018, MC-263

Austin, TX 78768-2018

Assistance in filing a complaint is available by calling 1-800-201-9353. For more information, visit www.tmb.state.tx.us

Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas:

Texas Medical Board Attention: Investigations 333 Guadalupe, Tower 3, Suite 610 P.O. Box 2018, MC-263 Austin, Texas 78768-2018

Si necesita ayuda para presentar una queja, lame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.

PRIVACY POLICY
M&D Integrations understands the importance of confidentiality and privacy regarding your health information. M&D Integrations will act in accordance with HIPAA to protect your private health information.



YOUR RELATIONSHIP WITH M&D INTEGRATIONS
M&D Integrations does not provide any medical services, including via the Sites and Services. Rather, M&D Integrations provides a technology platform for you to access a health care provider employed or contracted with M&D Integrations physicians or similar affiliated professional entities and obtain access to additional information, which you may or may not choose to utilize in planning your health care and wellness. The health and wellness resources made available through our Services are not a substitute for direct in-person health care services in all cases. The decision to focus on diagnosis, treatment recommendations, or both, rests with you and the health care provider. You understand that by coordinating and in certain cases consulting with M&D Integrations or affiliate health care provider through the Services, you are not entering into a provider-patient relationship with M&D Integrations itself.

By accepting the Terms of Use, you agree and consent to M&D Integrations, M&D Integrations affiliates, or health care providers sending you disclosures, notices, messages, reports, and other communications. It is your responsibility to monitor these communications. You acknowledge and agree that you will not hold us or any M&D Integrations affiliate liable for any loss, injury, or claim of any kind resulting from your failure to read these communications or for your failure to comply with any treatment recommendations contained in these communications.

CONSULTATIVE SERVICE
In some cases, a M&D Integrations physician or affiliated health care provider may use the Services to provide advice or treatment to you. A health care provider consulting with you through the Services may not have the benefit of information that would be obtained by examining you in person and observing your physical condition, in each instance. Therefore, the health care provider may not be aware of facts or information that may affect his or her opinion regarding a potential diagnosis or treatment recommendation. To reduce the risk to you of this limitation, M&D Integrations strongly encourages you to provide all relevant information and discuss any and all diagnosis and treatment options with a health care provider. Moreover, a health care provider utilizing M&D Integrations may be limited by state law in prescribing certain medications to you without first conducting an in-person physical examination. By deciding to engage the Services, you acknowledge and agree that you are aware of these limitations and agree to assume the risk of these limitations. Furthermore, you agree and accept that: (i)any diagnosis you may receive is limited and, in some cases, provisional;

(ii) the health care services are not intended, in all cases, to replace a full medical evaluation or an in-person visit with a health care provider; (iii) a health care provider acting through the Services may not have important information

that is usually obtained through a “hands-on” physical examination; and (iv) the absence of a physical examination may affect the health care provider’s ability to diagnose any potential condition, disease or injury.

For more information regarding the health care services offered by health care providers utilizing the Services, please visit mdintegrations.com.

SITE CONTENT
Except for specific communications received from your M&D Integrations physician or affiliate health care organizations and providers, none of the Content you receive through the Sites should be considered medical advice.

REGISTRATION AND USER ACCOUNTS
Although certain parts of the Sites are accessible by any individual, you are obligated to register with M&D Integrations in order to access the Services. The Services are available only to users who have registered with M&D Integrations and to other persons affiliated with M&D Integrations who have been granted accounts with usernames and passwords (“Secure Users”). If you are a Secure User, you agree to provide information that is accurate, complete and correct, and to accurately maintain and update any information about yourself that you have provided to M&D Integrations. If you do not maintain such information, or M&D Integrations has reasonable grounds to suspect as much, M&D Integrations has the right to suspend or terminate your account and your use of the Services. You agree to keep confidential your username and password and to exit from your Secure User account at the end of each session. You are responsible for all activities that occur under your account and for maintaining the confidentiality of your password. You are responsible for changing your password promptly if you think it has been compromised. You may not transfer or share your password with anyone, or create more than one account. You may not use anyone else’s account at any time. M&D Integrations explicitly disclaims liability for any and all losses and damages arising from your failure to comply with this section. You acknowledge and agree that: (1) all or any part of the Sites may not be accessible at any time, for any period, or for any reason; and (2) M&D Integrations will not be liable if for any reason all or any part of the Sites are unavailable at any time or for any period.

ACCESS RIGHTS AND PROHIBITED USE
Subject to your compliance with these Terms of Use, we hereby grant to you a personal, limited, revocable, non-exclusive, and nontransferable right to view, download, access, and use the Sites in the United States and to use the Services solely for your personal and non-commercial use and only as permitted under these Terms of Use, the Consent to Telehealth, and the Privacy Policy.

OWNERSHIP OF SITE CONTENT
As between M&D Integrations and you, M&D Integrations is the sole and exclusive owner of all right, title and interest in and to the Sites and their content, features and functionality, other Content, and all intellectual property rights therein, and any suggestions, ideas or other feedback provided by you.

LINKS TO THIRD-PARTY HYPERLINKS AND WEBSITES
The Sites may contain hyperlinks or references to other websites (“Linked Sites”) operated by third parties. The Linked Sites may not be under our control, therefore, we are not responsible for the information, products or services described thereon, or for the content of any Linked Site, including, without limitation, any link contained in a Linked Site, or any changes or updates to a Linked Site. We are providing these Linked Sites to you only as a convenience, and the inclusion of any link does not necessarily imply endorsement of the Linked Site or any association with its operators. Your use of these Linked Sites is at your own risk, and we are not liable to you in any way, either directly or indirectly, for any content, errors, damage or loss caused by or in connection with use of or reliance on information contained in or provided to Linked Sites.

You may have arrived to the Sites through a Linked Site, including a Linked Site controlled by a parent, subsidiary or affiliate of M&D Integrations. You understand and agree that we are not responsible for the information, products or services described on those Linked Sites and only these Terms of Use will apply to your use of or access to the Sites.

TERMINATION
The Terms of Use will remain in full force and effect as long as you continue to access or use the Sites or Services. You may terminate the Terms of Use at any time by discontinuing use of the Sites. Your permission to use the Sites automatically terminates if you violate these Terms of Use.

M&D Integrations may terminate or suspend any of the rights granted by these Terms of Use and your access to and use of the Sites or Services with or without prior notice, for any reason, and at any time. The following provisions survive the expiration or termination of these Terms of Use for any reason whatsoever: Disclaimer of Warranties; Limitation of Liability; Indemnification; Governing Law, Dispute Resolution, Venue, Severability of Provisions; No Waiver; and Assignment.

After such termination, M&D Integrations will have no further obligation to provide the Services, except to the extent an affiliated professional entity is obligated to provide you access to your health records or is required to provide you with continuing care under applicable legal, ethical and professional obligations to you.

DISCLAIMER OF WARRANTIES
YOU EXPRESSLY AGREE THAT USE OF THE SITES IS AT YOUR SOLE RISK. YOU ACKNOWLEDGE AND AGREE THAT THE SITES AND ANY SERVICES ARE PROVIDED THROUGH THE SITES ON AN “AS IS” AND “AS AVAILABLE” BASIS. M&D Integrations AND ITS AFFILIATES, INCLUDING WITHOUT LIMITATION ALL AFFILIATED PROFESSIONALS, PROFESSIONAL ENTITIES, AND THEIR RESPECTIVE OFFICERS, DIRECTORS, MANAGERS,

PARTNERS, MEMBERS, EMPLOYEES, AND AGENTS (COLLECTIVELY “RELATED PERSONS”) MAKE NO REPRESENTATIONS OR WARRANTIES AND EXPRESSLY DISCLAIM ANY AND ALL WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, WITH RESPECT TO THE SITES AND SERVICES INCLUDING, BUT NOT LIMITED TO, ANY REPRESENTATIONS OR WARRANTIES WITH RESPECT TO FITNESS FOR A PARTICULAR USE OR PURPOSE, NONINFRINGEMENT, TITLE, AVAILABILITY, SECURITY, OPERABILITY, CONDITION, QUIET ENJOYMENT, VALUE, ACCURACY OF DATA, FREEDOM FROM VIRUSES OR MALWARE, COMPLETENESS, TIMELINESS, FUNCTIONALITY, RELIABILITY, SEQUENCING OR SPEED OF DELIVERY OR SYSTEM INTEGRATION. WE MAKE NO WARRANTIES OR REPRESENTATIONS THAT YOUR USE OF THE SITES OR SERVICES WILL NOT INFRINGE THE RIGHTS OF THIRD PARTIES.

TO THE FULLEST EXTENT OF APPLICABLE LAW, NEITHER M&D Integrations NOR ITS RELATED PERSONS WILL BE LIABLE FOR ANY LOSS OR DAMAGE CAUSED BY YOUR RELIANCE ON INFORMATION OBTAINED THROUGH THE SITES. IT IS YOUR RESPONSIBILITY TO EVALUATE THE ACCURACY, COMPLETENESS, TIMELINESS, RELIABILITY OR USEFULNESS OF THE SITES. FURTHERMORE, M&D Integrations DOES NOT GUARANTEE THAT THE SITES WILL BE UNINTERRUPTED, OR FREE FROM ERROR, DEFECT, LOSS, DELAY IN OPERATION, CORRUPTION, CYBER ATTACK, VIRUSES, INTERFERENCE, HACKING, MALWARE, OR OTHER SECURITY INTRUSION, AND M&D Integrations DISCLAIMS ANY LIABILITY RELATING THERETO.

YOU UNDERSTAND AND AGREE THAT ANY CONTENT, MATERIAL AND/OR INFORMATION OBTAINED THROUGH THE USE OF THE SITES ARE USED AT YOUR SOLE RISK AND THAT YOU WILL BE SOLELY RESPONSIBLE FOR ANY DAMAGE TO YOUR COMPUTER OR MOBILE PHONE OR LOSS OF DATA THAT RESULTS FROM THE DOWNLOAD OF SUCH CONTENT, MATERIAL AND/OR INFORMATION.

LIMITATION OF LIABILITY
YOU UNDERSTAND THAT TO THE EXTENT PERMITTED UNDER APPLICABLE LAW AND EXCEPT AS SET FORTH IN THIS SECTION, IN NO EVENT WILL M&D Integrations, ITS RELATED PERSONS OR ENTITIES OR LICENSORS BE LIABLE TO YOU OR TO ANY PARTY FOR ANY CLAIMS, LIABILITIES, LOSSES, COSTS OR DAMAGES UNDER ANY LEGAL OR EQUITABLE THEORY, WHETHER IN TORT (INCLUDING NEGLIGENCE), CONTRACT, WARRANTY, OR OTHERWISE, INCLUDING, BUT NOT LIMITED TO, ANY INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL, PUNITIVE OR EXEMPLARY DAMAGES, OR FOR ANY DAMAGES FOR PERSONAL OR BODILY INJURY OR EMOTIONAL DISTRESS, INCLUDING DEATH, ARISING OUT OF OR IN CONNECTION WITH ANY ACCESS, USE OF (OR INABILITY TO USE) THE SITES OR ANY SERVICES PROVIDED THROUGH THE SITES, OR OTHER INTANGIBLE LOSSES ARISING OUT OF OR RELATED TO YOUR USE OF THE SITES. THIS IS TRUE EVEN IF M&D Integrations OR RELATED

PERSONS HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES OR LOSSES.

To the extent that we may not, as a matter of applicable law, disclaim any implied warranty or limit liabilities, the scope and duration of such warranty and the extent of our liability will be the minimum permitted under such applicable law.

INDEMNIFICATION
You agree to indemnify, defend, and hold harmless M&D Integrations, its affiliates (including without limitation all affiliated professionals and professional entities), subsidiaries, and their directors, officers, employees, contractors, licensors, representatives, proprietors, partners, shareholders, servants, principals, agents, assigns, and attorneys harmless from and against any and all third-party suits, actions, claims, proceedings, damages, settlements, judgments, injuries, liabilities, obligations, losses, risks, costs, and expenses (including, without limitation, reasonable attorneys’ fees, litigation expenses, and accounting fees), relating to or arising from, or alleged to arise from, your use of materials or features available on the Site.

MODIFICATIONS TO THE SITES
M&D Integrations reserves the right at any time and for any reason to modify, or temporarily or permanently discontinue, the Sites or Services or any portion thereof, with or without notice. You agree that M&D Integrations shall not be liable to you or to any third party for any modification, suspension, or discontinuance of the Site or Services.

PAYMENT
You agree to pay all fees due for services requested. You will see a prompt for your payment details, such as your credit card information and any promotional codes you may have. By entering your payment information and submitting your request, you authorize us, our affiliates, or our third-party payment processors to charge the amount due.

GOVERNING LAW; DISPUTE RESOLUTION; ARBITRATION; VENUE; SEVERABILITY OF PROVISIONS
PLEASE READ THIS SECTION CAREFULLY BECAUSE IT REQUIRES YOU AND M&D Integrations TO RESOLVE ALL DISPUTES BETWEEN US AND LIMITS THE MANNER IN WHICH YOU CAN SEEK RELIEF FROM M&D Integrations.

These Terms of Use and your use of the Sites shall be governed by the laws of the State of New York, without giving effect to the principles of conflict of laws. Any dispute arising under or relating in any way to these Terms of Use will be resolved exclusively in the County of Nassau, New York. The parties agree that the Supreme Court of the State of New York located in Nassau County, New York shall have exclusive personal jurisdiction, subject matter jurisdiction, and venue for any such claim.

All parts of these Terms of Use apply to the maximum extent permitted by law. M&D Integrations and you both agree that if we cannot enforce a part of this contract

as written, then that part will be replaced with terms that most closely match the intent of the part we cannot enforce, to the extent permitted by law.
The invalidity of part of these Terms of Use will not affect the validity and enforceability of the remaining provisions. The section headings are for convenience only and do not have any force or effect.

NO WAIVER
No waiver by M&D Integrations of any term or condition set forth in these Terms of Use shall be deemed a further or continuing waiver of such term or condition or a waiver of any other term or condition, and any failure by M&D Integrations to assert a right or provision under these Terms of Use shall not constitute a waiver of such right or provision.

REMEDIES
You agree that any violation, or threatened violation, by you of these Terms of Use constitutes an unlawful and unfair business practice that will cause us irreparable and unquantifiable harm. You also agree that monetary damages would be inadequate for such harm and consent to our obtaining any injunctive or equitable relief that we deem necessary or appropriate. These remedies are in addition to any other remedies we may have at law or in equity.

ASSIGNMENT
You may not assign any of your rights under this agreement, and any such attempt will be null and void.

DIGITAL MILLENNIUM COPYRIGHT ACT
M&D Integrations reserves the right to remove any content or any other material or information available on or through our Sites, at any time, for any reason. M&D Integrations otherwise complies with the provisions of the Digital Millennium Copyright Act (“DMCA”) applicable to Internet service providers (17 U.S.C. § 512, as amended), and responds to clear notices of alleged copyright infringement. This Section describes the procedure that should be followed to file a notification of alleged copyright infringement with M&D Integrations

Notification of Claimed Copyright Infringement. If you have objections to copyrighted content or material made available on or through our Sites, you may submit a notification to our Designated Agent at the following address: courtney@mdintegrations.com

Any notification to M&D Integrations under 17 U.S.C. § 512(c) alleging copyright infringement must include the following information:

  • An electronic or physical signature of the person authorized to act on behalf of the owner of the exclusive right being infringed;
  • An identification of the copyrighted work or other intellectual property that you claim has been infringed or, if multiple copyrighted works are covered by a single notification, a representative list of such works;
  • An identification of the content or material that you claim is infringing and where it is located on our Sites;
  • Information sufficient for M&D Integrations to contact you, such as your address, telephone number, and/or email address;
  • A statement by you that you have a good-faith belief that the use of the content or material of which you are complaining is not authorized by the copyright owner, its agent, or the law; and
  • A signed statement by you that the above information in your notice is accurate and that, under penalty of perjury, you are the copyright owner or authorized to act on the copyright owner’s behalf.

HIPAA (Health Information Portability and Accountability) Information

Uses and disclosures of your protected health information that do not require an authorization

Treatment. For example, doctors, nurses, and other staff members involved in your care will use your PHI to coordinate your care or to plan a course of treatment for you.

Payment. For example, we may disclose information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you.

Health Care Operations. For example, we may disclose your PHI for billing or interpreter support. We may use your PHI to conduct an evaluation of the treatment and services provided or to review staff performance.

Communicating with You. We will use your PHI to communicate with you about a number of important topics, including information about your care, treatment options and other health-related services

We may also contact you at the email, phone number or address that you provide, including via text messages, for these communications. If your contact information changes, it is important that you let us know. We will only provide you a link via text or e-mail which will require you to verify yourself prior to opening the message within the MDI messaging portal.

Business Associates. At times, we need to disclose your PHI to persons or organizations outside MDI who assist us with our payment/billing and health care operations. We require these business associates and their subcontractors to appropriately safeguard your PHI.

Other Uses and Disclosures. We may be permitted or required by law to make certain other uses and disclosures of your PHI without your authorization. Subject to conditions specified by law, we may release your PHI:

  • for any purpose required by law
  • for public health activities, including required reporting of disease, injury, birth and death, for required public health investigations, and to report adverse events or enable product recalls
  • to government agencies if we suspect child/elder adult abuse or neglect. We may also release your PHI to government agencies if we believe you are a victim of abuse, neglect or domestic
  • to your employer when we have provided screenings and health care at their request for occupational health and safety
  • to a government oversight agency conducting audits, investigations, inspections and related oversight functions
  • in emergencies, such as to prevent a serious and imminent threat to a person or the public
  • if required by a court or administrative order, subpoena or discovery request
  • for law enforcement purposes, including to law enforcement officials to identify or locate suspects, fugitives or witnesses, or victims of crime
  • to coroners, medical examiners and funeral directors
  • if necessary to arrange organ or tissue donation or transplant
  • for national security, intelligence, or protective services activities
  • for purposes related to your workers’ compensation benefits

Uses and disclosures of your protected health information based on a signed authorization

Except as outlined above, we will not use or disclose your PHI for any other purpose unless you have signed a form authorizing the use or disclosure. You may revoke an authorization in writing, except to the extent we have already relied upon it.

In some situations, a signed authorization form is required for uses and disclosures of your PHI, including:

  • most uses and disclosures of psychotherapy notes
  • uses and disclosures for marketing purposes
  • disclosures that constitute the sale of PHI
  • uses and disclosures for certain research protocols
  • as required by privacy law. The confidentiality of substance use disorder and mental health treatment records as well as HIV-related information maintained by us is specifically protected by state and/or federal law and regulations. Generally, we may not disclose such information unless you consent in writing, the disclosure is allowed by a court order, or in other limited, regulated circumstances.


Your rights

Access to Your PHI. You can access and inspect paper or electronic copies of certain PHI that we maintain about you. You may readily access much of your health information without charge using the following link: https://privacy.mdintegrations.com. In line with set fees under federal and state law, we may charge you for a copy of your medical records.

Amendments to Your PHI. You can request amendments, or changes, to certain PHI that we maintain about you that you think may be incorrect or incomplete. All requests for changes must be in writing, signed by you or your representative, and state the reasons for the request. If we decide to make an amendment, we may also notify others who have copies of the information about the change. Note that even if we accept your request, we may not delete any information already documented in your medical record.  You can make such requests by contacting support@mdintegrations.com or directly inside your MDI patient portal under the “privacy center” section.

Accounting for Disclosures of Your PHI. In accordance with applicable law, you can ask for an accounting of certain disclosures made by us of your PHI. This request must be in writing and signed by you or your representative. This does not include disclosures made for purposes of treatment, payment, or health care operations or for certain other limited exceptions. An accounting will include disclosures made in the six years prior to the date of a request.

Restrictions on Use and Disclosure of Your PHI. You can request restrictions on certain of our uses and disclosures of your PHI for treatment, payment, or health care operations. We are not required to agree but will attempt to accommodate reasonable requests when appropriate.

Restrictions on Disclosures to Health Plans. You can request a restriction on certain disclosures of your PHI to your health plan. We are only required to honor such requests when services subject to the request are paid in full. Such requests must be made in writing and identify the services to which the restriction will apply.

Confidential Communications. You can request that we communicate with you through alternative means or at alternative locations, and we will accommodate reasonable requests. You must request such confidential communication in writing to each department you would like to accommodate the request.

Breach Notification. We are required to notify you in writing of any breach of your unsecured PHI without unreasonable delay and no later than 60 days after we discover the breach.

Additional Information

Complaints. If you believe your privacy rights have been violated, you can file a complaint with the MD Integrations privacy officer (Ana Ramos) by contacting support@mdintegrations.com or calling 6297775752.

You can also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington D.C.

A complaint must be made in writing and will not in any way affect the quality of care we provide you.