Notice of Privacy Practices Acknowledgment

I acknowledge that I have received or had the opportunity to review MLPA’s Notice of Privacy Practices or the applicable provider Notice of Privacy Practices before receiving Covered MLPA Services.

• The Notice describes how protected health information (PHI) may be used and disclosed for treatment, payment, healthcare operations, and other purposes permitted or required by law.

• The Notice describes my HIPAA rights, including rights to access, request amendment, request restrictions, request confidential communications, receive an accounting of certain disclosures, receive a paper copy, receive breach notices, and file complaints without retaliation.

• I understand that acknowledgment of the Notice is not the same as authorizing uses or disclosures of PHI that require a separate HIPAA authorization.

• I understand that non-HIPAA information, such as website/app data, Mya chats outside a HIPAA-covered workflow, membership data, e-commerce data, and Consumer Health Data outside a covered clinical workflow, may be governed by MLPA’s other privacy notices.