Availability of Experimental/Investigational Services

Our clinic provides experimental/investigational services which in many cases are novel/cutting-edge/unproven therapies. These include procedures, drugs, and other therapeutics that are approved by the Food and Drug Administration but being used in a manner that is not consistent with the labeling of the product. Services may also include novel surgical procedures that have a limited track record in the medical literature and therefore may include unanticipated risks, including the need to operate to correct an unintended consequence or severe risks. I understand I have the right to discuss these potential risks extensively with my physician and decide with him about the costs and potential benefits and likelihood of benefits prior to proceeding with any of these experimental/investigational/unproven/novel therapies.

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.

This Notice describes how we may use and disclose your protected health information (PHI), your rights concerning your PHI, and our legal duties to protect your information. We are required by law to maintain the privacy and security of your PHI, to provide you with this Notice of our legal duties and privacy practices, and to follow the duties and privacy practices described in this Notice. We are required to notify you promptly if a breach occurs that may have compromise d the privacy or security of your PHI. We will not use or disclose your PHI other than as described in this Notice unless you authorize us to do so in writing. We reserve the right to change the terms of this Notice and to make the revised Notice effective for all PHI we maintain. Any revised Notice will be posted in our office and on our website and will be available upon request. We may use and disclose your PHI for purposes of treatment, payment, and health care operations. For treatment, we may disclose your information to physicians, nurses, pharmacies, hospitals, or other health care providers involved in your care, and we may contact you to provide appointment reminders or information about treatment alternatives or health-related benefits and services that may be of interest to you. For payment, we may use and disclose your information to bill and collect payment from health plans or other entities. For health care operations, we may use and disclose your information to operate our practice, improve quality of care, train staff, conduct compliance activities, and manage administrative functions. We may also use or disclose your PHI without your authorization as required or permitted by federal or Ohio law, including for public health reporting, reporting abuse or neglect, health oversight activities, judicial or administrative proceedings pursuant to lawful process, law enforcement purposes, workers’ compensation matters, to avert a serious threat to health or safety, for specialized government functions, to coroners or medical examiners, for organ donation purposes, and for approved research activities conducted under appropriate safeguards. Unless you object, we may disclose relevant information to a family member, close personal friend, or other person involved in your care or payment for your care, limited to information directly relevant to that person’s involvement. You may object to such disclosures at any time. We do not sell PHI. We do not use PHI for marketing purposes. We do not engage in fundraising activities. We do not create or maintain psychotherapy notes. If in the future any such activity were contemplated, we would obtain your written authorization as required by law. Other uses and disclosures not described in this Notice will be made only with your written authorization, and you may revoke your authorization at any time in writing, except to the extent that we have already acted in reliance upon it. You have the right to inspect and obtain a copy of your PHI that is used to make decisions about your care or payment for your care. We will act on your request no later than thirty days after receipt of a valid written request, with one additional thirty-day extension permitted if necessary as allowed by law. We may charge a reasonable, cost-based fee for copies consistent with applicable federal standards and Ohio law, including Ohio Revised Code sections governing medical record production and fee limitations. You have the right to request an amendment of your PHI if you believe it is inaccurate or incomplete; we may deny your request if the information was not created by us or is accurate and complete. You have the right to request restrictions on certain uses or disclosures of your information; while we are not required to agree to most requested restrictions, we will comply with a request to restrict disclosure to a health plan regarding a service for which you have paid in full out of pocket as required by federal law. You have the right to request confidential communications by alternative means or at alternative locations, and we will accommodate reasonable requests. You have the right to receive an accounting of certain disclosures of your PHI made outside of treatment, payment, and health care operations. The first accounting requested within a twelve-month period will be provided without charge; subsequent accountings within the same period may be subject to a reasonable cost-based fee. You have the right to obtain a paper copy of this Notice at any time upon request. Certain categories of information may receive additional protections under state or federal law. Information relating to HIV testing or HIV status is subject to specific confidentiality protections under Ohio law, and such information will not be disclosed except as permitted or required by applicable law. Certain minor patients may have rights under Ohio law to consent to specific types of care, and in those circumstances parental or guardian access to related records may be limited as permitted by law. Records related to substance use disorder diagnosis, treatment, or referral for treatment may be protected under federal law at 42 U.S.C. 290dd-2 and 42 CFR Part 2. To the extent we create, receive, maintain, or transmit records that are subject to 42 CFR Part 2, those records will be handled in accordance with applicable federal requirements. Under current federal regulations effective in 2026, substance use disorder records may be used or disclosed for treatment, payment, and health care operations in accordance with a valid patient consent that permits such uses and disclosures, consistent with Part 2 and HIPAA alignment requirements. Such records remain subject to heightened confidentiality protections and restrictions on redisclosure as required by law. Substance use disorder records generally may not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you without your written consent or a court order that complies with applicable federal requirements. You may revoke a Part 2 consent in writing at any time except to the extent action has already been taken in reliance upon it. Complaints regarding the confidentiality of substance use disorder records may be made to our Privacy Officer or to the Secretary of the U.S. Department of Health and Human Services. If you believe your privacy rights have been violated, you may file a written complaint with our Privacy Officer or with the Secretary of the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint. For questions about this Notice, to exercise any of your rights, or to file a complaint, please contact our Privacy Officer: Melanie Clark, 770 Jasonway Ave, Suite 1B, Columbus, Ohio 43214, telephone (614) 867-3681, email melanie@usasinus.org Effective Date: February 16, 2026.

Consent for Electronic Communication (Email, Text, Phone, Video, Website Messaging)

I understand that we may communicate about my care, scheduling, billing, and other health-related matters by telephone, voicemail, email, text message, video communication, and through messaging tools on our website or other electronic systems. I understand that standard email and text messaging may not be encrypted and may carry a risk that PHI could be intercepted, misdirected, accessed by someone who uses my device or email account, or otherwise disclosed without authorization. I understand that HIPAA permits electronic communication with patients when reasonable safeguards are used, and that if I request communication through unencrypted email or text message after being informed of the risks, we may honor that request. I have been offered the option to communicate through more secure methods when available and I may change my communication preferences at any time. I may also request that USIASCR contact me by alternative means or at alternative locations, and we will accommodate reasonable requests as required by law. By signing below, I authorize the practice to communicate with me using the electronic methods I choose or use to contact the practice (including email and text). I understand that I should notify the practice promptly if my email address, phone number, or device access changes (for example, if I share a phone, change numbers, lose a device, or no longer control an email account). I understand that this consent remains in effect until I revoke or modify it in writing. Revocation will apply going forward and will not affect communications already sent or actions already taken in reliance on this consent. To the extent I request that communications include sensitive information, I understand additional federal and state confidentiality protections may apply in certain circumstances, including protections related to substance use disorder records that may be subject to 42 U.S.C. 290dd-2 and 42 CFR Part 2, which have civil enforcement beginning February 16, 2026.

Assignment of Insurance Benefits / Authorization to Release Information / Medicare Authorization

I certify that the insurance information I provide is accurate and that I am eligible for the coverage indicated. I understand that I am financially responsible for all charges for services provided to me, including deductibles, copayments, coinsurance, non-covered services, and any charges not paid by my insurance plan, regardless of whether my claim is paid or denied. I hereby authorize my insurance plan(s) and any other payer (including Medicare, Medicaid, and secondary payers) to pay benefits directly to the practice for professional services rendered (assignment of benefits), up to the amount of my financial responsibility to the practice. I authorize the practice to release PHI to my health plan(s) and other payers, and to their contractors or agents, as necessary to obtain payment and to process claims, including determining eligibility, coverage, medical necessity, and benefits payable. This authorization includes, when applicable, releasing information necessary for coordination of benefits with secondary insurance. MEDICARE BENEFICIARIES: I request that payment of authorized Medicare benefits be made either to me or on my behalf to the practice for any services furnished to me by the practice. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services, consistent with Medicare claims requirements. This assignment and authorization will remain in effect until I revoke it in writing, except to the extent that action has already been taken in reliance on it. I understand that this assignment does not eliminate my obligation to pay amounts that are my responsibility under my insurance plan or under Medicare.