Revitalized Wellness, PLLC — Notice of Privacy Practices

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and shared, and how you can get this information. Please review it carefully. If you have questions, contact our Privacy Officer at (541) 214-2786.

Your rights

When it comes to your health information, you have the right to:

• Get a copy of your medical record. Ask us for a paper or electronic copy. We will usually provide it within 30 days. We may charge a reasonable, cost-based fee.
• Ask us to correct your record. If you think something is wrong or missing, ask us in writing. If we say no, we will tell you why in writing within 60 days.
• Ask for confidential communications. You can ask us to contact you a certain way (for example, a different phone or address). We will say yes to all reasonable requests.
• Ask us to limit what we use or share. We are not required to agree, and we may say no if it would affect your care. If you pay for a service in full out of pocket, you can ask us not to share that information with your health insurer, and we will agree unless the law requires us to share it.
• Get a list of who we have shared your information with for up to six years before the date you ask, who we shared it with, and why. This list does not include sharing for treatment, payment, health care operations, or sharing you asked us to do. One list a year is free; we may charge a reasonable fee for more.
• Get a paper copy of this notice at any time, even if you agreed to get it electronically.
• Choose someone to act for you. If someone has medical power of attorney or is your legal guardian, they can use your rights. We will confirm their authority first.
• File a complaint if you feel your rights have been violated (see "Complaints" below). We will not retaliate against you for filing a complaint.

Your choices

You can tell us your choices about sharing with family, close friends or others involved in your care, and in disaster relief situations. If you cannot tell us (for example, if you are unconscious), we may share information if we believe it is in your best interest, or to lessen a serious and imminent threat to health or safety.

We never share your information for marketing, never sell your information, and do not share most psychotherapy notes without your written permission.

Fundraising: We may contact you about fundraising. You can tell us not to contact you again. For SUD treatment records, we will give you clear notice in advance and a choice before using them for any fundraising communication.

How we use and share your health information

• Treatment: to provide and coordinate your care with other professionals treating you.
• Running our practice: to operate the clinic, improve care, and contact you when needed (including appointment reminders).
• Billing: to bill and get payment from health plans or other entities.

We may also share information, when allowed or required by law, for: public health and safety (such as reporting disease, preventing disease, reporting suspected abuse, neglect or domestic violence, adverse drug reactions, or preventing a serious threat to health or safety); research that meets legal requirements (we do not currently use your information for research); complying with the law, including HHS reviews; organ and tissue donation; medical examiners and funeral directors; workers' compensation, law enforcement and other government requests (such as health oversight agencies and special government functions); and responding to lawsuits, court orders or subpoenas.

Special protection for substance use disorder (SUD) treatment records

If you receive SUD treatment from us (for example, medication for opioid or alcohol use disorder), federal law (42 U.S.C. 290dd-2 and 42 CFR Part 2) gives those records extra protection:

• Your written consent is required for most uses and sharing of your SUD records, including for treatment, payment and health care operations. You may give a single consent for all future treatment, payment and health care operations uses. You may revoke your consent in writing at any time, except for actions already taken.
• Limited sharing without consent is allowed only in specific situations: medical emergencies, FDA product-safety reports, suspected child abuse or neglect reports, crimes on our premises or against our staff, certain audits and evaluations, scientific research without patient identifiers, cause-of-death inquiries, and a court order that meets Part 2 requirements.
• Not used against you in legal proceedings. We will not use or share your SUD records, or testimony about them, in any civil, criminal, administrative or legislative investigation or proceeding against you unless you give written consent, or a court issues an order that meets Part 2 requirements and is accompanied by a subpoena or similar legal mandate. You will be given notice and an opportunity to be heard first.
• Redisclosure: If we share your SUD records with another HIPAA-covered provider or health plan under your consent for treatment, payment or operations, they may further use or share the records as HIPAA allows, but they still may not use them against you in legal proceedings without your consent or a qualifying court order.
• Additional rights for SUD records: you may ask for a list of disclosures made with your consent, ask us to limit sharing, and get this notice on paper.

Our responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. You may change your mind at any time by telling us in writing.

State law

We are not aware of any state laws that limit these uses and disclosures more than federal law.

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 clinics, and on our website at www.revitalizedwellness.org.

Complaints

You can complain to us by contacting our Privacy Officer at (541) 214-2786. We will help you write your complaint if you ask.

You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue S.W., Washington, D.C. 20201, calling 1-800-368-1019 (TDD 1-800-537-7697), or filing online at ocrportal.hhs.gov. Complaints about SUD records can be filed the same way.

We will not retaliate against you for filing a complaint.

Effective date

This notice is effective November 5, 2026. It replaces our notice dated July 1, 2020.

Revitalized Wellness, PLLC
Eugene, OR clinic: 71 Centennial Loop, Eugene, OR · (541) 214-2786
Red Oak, IA clinic (by appointment): 1981 G Ave, Red Oak, IA · (712) 717-0300
Florida: telehealth only · (941) 231-7642
Mailing address: 401 E 8th St, Ste 214-7054, Sioux Falls, SD 57103
www.revitalizedwellness.org