Your Information. Your Rights. Our Responsibilities.

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.

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds

Our Uses and Disclosures

We may use and share your information as we:

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

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.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• 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). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

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 health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• You can 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 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.

Your Choices

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, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information?

• We typically use or share your health information in the following ways.

Treat you

• We can use your health information and share it with other professionals who are treating you.
• Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

• We can use and share your health information to run our practice, improve your care, and contact you when necessary.
• Example: We use health information about you to manage your treatment and services.

Bill for your services

• We can use and share your health information to bill and get payment from health plans or other entities.
• Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
• Do research
• We can use or share your information for health research.
• Comply with the law – We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
• Respond to organ and tissue donation requests
• We can share health information about you with organ procurement organizations.
• Work with a medical examiner or funeral director
• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
• Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services
• Respond to lawsuits and legal actions
• We can share health information about you in response to a court or administrative order, or in response to a subpoena.

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. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
• For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Use of Cookies

The Web site uses “cookies” to help this Practice personalize your online experience. A cookie is a text file that is placed on your hard disk by a Web page server. Cookies cannot be used to run programs or deliver viruses to your computer. Cookies are uniquely assigned to you, and can only be read by a web server in the domain that issued the cookie to you.

Security of your Personal Information

This Practice secures your personal information from unauthorized access, use or disclosure. This Practice secures the personally identifiable information you provide on computer servers in a controlled, secure environment, protected from unauthorized access, use or disclosure. When personal information (such as a credit card number) is transmitted to other Web sites, it is protected through the use of encryption, such as the Secure Socket Layer (SSL) protocol.

Changes to the Terms of 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 upon request, in our office, and on our web site.

SMS & Email Privacy Policy Informed Consent

Consent for SMS Communications

Matrix Reformed respects your privacy and autonomy in choosing how we communicate with you. To comply with legal requirements and ensure we engage with you via your preferred methods, we seek your explicit consent for communications through SMS, which may include:

Exclusive promotions and specials

• Tailored offers
• Updates on new services
• Personalized discounts
• Member-only deals

SMS Communications Consent: When you provide your mobile number and check the box below, you expressly consent to receive SMS messages from Matrix Reformed.

This may involve messages delivered via an automated system, and standard message and data rates may apply.

Please acknowledge your consent for SMS: I have read and explicitly consent to receive SMS messages from Matrix Reformed about promotions, specials, offers, new services, and discounts.

I confirm that I am providing this consent freely and have not been previously solicited by SMS prior to providing my mobile number.

I understand that I can opt out of SMS communications at any time by replying “STOP” to any message I receive, or by other means provided in the SMS communication, and that my opt-out will be effective upon Matrix Reformed receipt and processing of my request.

I am aware that my consent to receive SMS messages is not required to purchase any goods or services from Matrix Reformed, and I can choose other forms of communication messages.

I understand that I may revoke my consent at any time and request a copy of this consent form by contacting Matrix Reformed directly. Matrix Reformed commits to maintaining the confidentiality of your personal information and will not share or sell your details to third parties.

SMS opt-in information and phone numbers collected for SMS purposes are not being shared with third parties

Affirmation of Consent: By Agreeing below, I confirm that I have thoroughly read, fully understood, and agree to the terms of this SMS communications consent form.

If you have questions or need further clarification about this consent form or our SMS practices, please contact our SMS Manager at [email protected].

Consent for Email Marketing Communications

The law requires that we obtain your consent to contact you for marketing purposes, which may include, but are not limited to, the following:

• Promotions
• Specials
• Offers
• New services
• Discounts

The contact information you provided on your intake paperwork, including your mail, email, telephone, cellphone, and/or text message details, will be used for solicitation purposes. Communications may include the use of pre-recorded voice messages and autodial systems.

By checking this box, you certify that:

You have read and agree to the above solicitation method(s).

You were not previously solicited by any of the above means prior to the date indicated below.

At any time, if you choose to opt-out, you will notify Matrix Reformed in writing or by the opt-out method(s) provided in the communication you receive.

Please note: Your consent to receive marketing communications is not a condition of purchasing any goods or services from Matrix Reformed.

You may revoke your consent at any time by following the opt-out instructions provided in the marketing communications or by contacting Matrix Reformed directly.

Matrix Reformed will not share or sell your personal information to third parties for their marketing purposes without your explicit consent.

You have the right to request a copy of this consent form for your records.

By agreeing below, you acknowledge that you have read, understood, and agree to the terms of this consent for marketing communications.

I consent to receive marketing communications from Matrix Reformed.

If you have any questions or concerns about this consent form or our marketing practices, please contact our Marketing Manager.

Contact for Privacy Inquiries

If you have any questions about this privacy notice, your privacy rights, or how we use your information, you may contact us at:

Privacy Officer Contact Information:

Matrix Reformed, LLC
Email: [email protected]
Phone: 727-748-1880
Mailing Address: Matrix Reformed, LLC ATTN: Privacy Office | 7901 4th St N #25584., St Petersburg, FL 33702

We are committed to addressing your inquiries promptly and ensuring the protection of your personal information.

This was last updated: 2/01/2025.