WELLVIA PRIVACY POLICY

NOTICE OF PRIVACY PRACTICES

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.

WellVia’s Commitment To Your Privacy

WellVia on behalf of the professional corporations for which WellVia provides business, management, and other administrative services, and the Wellspring Physician P.C(s), (collectively “WellVia”) are dedicated to maintaining the privacy of your protected health information (‘PHI’). PHI is information about you that may be used to identify you (such as your name, social security number or address), and that relates to (a) your past, present or future physical or mental health or condition, (b) the provision of health care to you, or (c) your past, present, or future payment for the provision of health care. In conducting its business, WellVia will receive and create records containing your PHI. WellVia is required by law to maintain the privacy of your PHI and to provide you with notice of its legal duties and privacy practices with respect to your PHI.

WellVia must abide by the terms of this Notice while it is in effect. This current Notice takes effect on January 1st, 2014, and will remain in effect until WellVia replaces it. WellVia reserves the right to change the terms of this Notice at any time, as long as the changes are in compliance with applicable law. If WellVia changes the terms of this Notice, the new terms will apply to all PHI that it maintains, including PHI that was created or received before such changes were made. If WellVia changes this Notice, it will post the new Notice on its Web site and will make the new Notice available upon request.

Uses And Disclosures Of PHI

WellVia may use and disclose your PHI in the following ways:

Treatment, Payment and Health Care Operations. WellVia is permitted to use and disclose your PHI for purposes of (a) treatment, (b) payment and (c) health care operations. For example:

Treatment. WellVia may disclose your PHI to another physician or health care provider for purposes of a consult or in connection with the provision of follow-up treatment.

Payment. WellVia may use and disclose your PHI to your health insurer or health plan in connection with the processing and payment of claims and other charges.

Health Care Operations. WellVia may use and disclose your PHI in connection with its health care operations, such as providing customer services and conducting quality review assessments. WellVia may engage third parties to provide various services for WellVia. If any such third party must have access to your PHI in order to perform its services, WellVia will require that third party to enter an agreement that binds the third party to the use and disclosure restrictions outlined in this Notice.

Authorization. WellVia is permitted to use and disclose your PHI upon your written authorization, to the extent such use or disclosure is consistent with your authorization. You may revoke any such authorization at any time.

As Required by Law. WellVia may use and disclose your PHI to the extent required by law.

Special Circumstances

The following categories describe unique circumstances in which WellVia may use or disclose your PHI:

Public Health Activities. WellVia may disclose your PHI to public health authorities or other governmental authorities for purposes including preventing and controlling disease, reporting child abuse or neglect, reporting domestic violence and reporting to the Food and Drug Administration regarding the quality, safety and effectiveness of a regulated product or activity. WellVia may, in certain circumstances disclose PHI to persons who have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.

Workers’ Compensation. WellVia may disclose your PHI as authorized by, and to the extent necessary to comply with, workers’ compensation programs and other similar programs relating to work-related illnesses or injuries.

Health Oversight Activities. WellVia may disclose your PHI to a health oversight agency for authorized activities such as audits, investigations, inspections, licensing and disciplinary actions relating to the health care system or government benefit programs.

Judicial and Administrative Proceedings. WellVia may disclose your PHI, in certain circumstances, as permitted by applicable law, in response to an order from a court or administrative agency, or in response to a subpoena or discovery request.

Law Enforcement. WellVia may, under certain circumstances, disclose your PHI to a law enforcement official, such as for purposes of identifying or locating a suspect, fugitive, material witness or missing person.

Decedents. WellVia may, under certain circumstances, disclose PHI to coroners, medical examiners and funeral directors for purposes such as identification, determining the cause of death and fulfilling duties relating to decedents.

Organ Procurement. WellVia may, under certain circumstances, use or disclose PHI for the purposes of organ donation and transplantation.

Research. WellVia may, under certain circumstances, use or disclose PHI that is necessary for research purposes.

Threat to Health or Safety. WellVia may, under certain circumstances, use or disclose PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

Specialized Government Functions. WellVia, may in certain situations, use and disclose PHI of persons who are, or were, in the Armed Forces for purposes such as ensuring proper execution of a military mission or determining entitlement to benefits. WellVia may also disclose PHI to federal officials for intelligence and national security purposes.

Your Rights Regarding Your PHI

You have the following rights regarding the PHI maintained by WellVia:

Confidential Communication. You have the right to receive confidential communications of your PHI. You may request that WellVia communicate with you through alternate means or at an alternate location, and WellVia will accommodate your reasonable requests. You must submit your request in writing to WellVia.

Restrictions. You have the right to request restrictions on certain uses and disclosures of PHI for treatment, payment or health care operations. You also have the right to request that WellVia restrict its disclosures of PHI to only certain individuals involved in your care or the payment of your care. You must submit your request in writing to WellVia. WellVia is not required to comply with your request. However, if WellVia agrees to comply with your request, it will be bound by such agreement, except when otherwise required by law or in the event of an emergency.

Inspection and Copies. You have the right to inspect and copy your PHI. You must submit your request in writing to WellVia. WellVia may impose a fee for the costs of copying, mailing, labor and supplies associated with your request. WellVia may deny your request to inspect and/or copy your PHI in certain limited circumstances. If that occurs, WellVia will inform you of the reason for the denial, and you may request a review of the denial.

Amendment. You have a right to request that WellVia amend your PHI if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is maintained by WellVia. You must submit your request in writing to WellVia and provide a reason to support the requested amendment. WellVia may, under certain circumstances, deny your request by sending you a written notice of denial. If WellVia denies your request, you will be permitted to submit a statement of disagreement for inclusion in your records.

Accounting of Disclosures. You have a right to receive an accounting of all disclosures WellVia has made of your PHI. However, that right does not include disclosures made for treatment, payment or health care operations, disclosures made to you about your treatment, disclosures made pursuant to an authorization, and certain other disclosures. You must submit your request in writing to WellVia and you must specify the time period involved (which must be for a period of time less than six years from the date of the disclosure). Your first accounting will be free of charge. However, WellVia may charge you for the costs involved in fulfilling any additional request made within a period of 12 months. WellVia will inform you of such costs in advance, so that you may withdraw or modify your request to save costs.

Breach Notification. You have the right to be notified in the event that WellVia (or a WellVia Business Associate) discovers a breach of unsecured PHI.

Paper Copy. You have the right to obtain a paper copy of this Notice from WellVia at any time upon request. To obtain a paper copy of this notice, please contact WellVia by calling 1.855.WellVia.

Complaint. You may complain to WellVia and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. To file a complaint with WellVia, you must submit a statement in writing to WellVia: Attn: Chief Compliance Officer, 309 North Washington Avenue, Suite 13, Bryan TX 77803. WellVia will not retaliate against you for filing a complaint.

Further Information. If you would like more information about your privacy rights, please contact WellVia by calling 1.855.WellVia and ask to speak to the Chief Compliance Officer. To the extent you are required to send a written request to WellVia to exercise any right described in this Notice, you must submit your request to WellVia at: Attn: Chief Compliance Officer, 309 North Washington Avenue, Suite 13, Bryan TX 77803.