Effective Date: 08/2025

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 privacy is important. We are committed to protecting your health information. This Notice explains how we may use and share your medical information, and describes your rights and our responsibilities regarding that information.

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 a copy of your medical record and other health information we have about you. We will provide a copy or a summary of your health records, usually within 30 days of your request. We may charge a reasonable, cost-based fee for copies.

• Ask us to correct your medical record: If you think health information we have about you is incorrect or incomplete, you can ask us to correct it. 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, on your personal phone instead of your work 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 every request, and we may decline if it would affect your care. However, if you pay for a service or health care item out-of- pocket in full, you can ask us not to share that specific information with your health insurer. We will say “yes” to this request 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 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 fee if you request another 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 it 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 honor their requests.

• File a complaint if you feel your rights are violated: You can complain if you feel we have violated your privacy rights by contacting us using the information at the end of this Notice. You can also file a complaint with the U.S. Department of Health and Human Services (Office for Civil Rights). We will not retaliate against you for filing a complaint. (See Questions and Complaints at the end of this Notice for more information on how to file 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, let us know.

• Involve others in your care: We may share your information with your family, close friends, or others involved in your care or payment for your care if you give us permission. You have the right and choice to tell us not to share your information with certain people. If you are unable 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 or necessary to help with your care. We may also share your information in a disaster relief situation to help notify others of your condition, status, or location.

• Hospital directory (if applicable): If you are admitted to a hospital or similar facility that maintains a patient directory, we may include certain limited information about you (such as your name, location in the facility, general condition, and religious affiliation) in the directory. This is so your family, friends, and clergy can visit you and generally know how you are doing. We will not include you in the directory if you instruct us not to. (This choice applies only to entities that maintain a directory, such as hospitals.)

• Fundraising communications: We may contact you for fundraising efforts to support our mission. If we do contact you, you have the right to opt out of receiving further fundraising communications. If you tell us not to contact you again for fundraising, we will honor that request.

Note: In the following situations, we will never share your information unless you give us written permission: for marketing purposes, the sale of your information, or most uses and disclosures of psychotherapy notes. (Using and sharing your information for these purposes requires your explicit authorization under the law.)

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 to provide and coordinate your care. For example, a doctor treating you for an injury may review your medical history or ask 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 manage our services. This includes business activities such as internal administration, data analysis, and quality improvement. For example, we may use health information about you to manage your treatment and services, train staff, evaluate the performance of our staff, or make decisions about opening new clinics.

• Bill for your services: We can use and share your health information to bill and get payment from health plans or other entities. For example, we might need to give information about a health service you received to your insurance company so it will pay us for the service.

In addition to the above, 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 or research. We have to meet many conditions in the law before we can share your information for these purposes. Here are some of those situations:

• Help with public health and safety issues: We can share health information about you for certain public health and safety purposes, such as:
• Preventing or controlling disease, injury, or disability
• Reporting births and deaths
• Reporting product recalls or problems with medications or devices
• Notifying people of exposures to communicable diseases
• Reporting suspected abuse, neglect, or domestic violence (when required or authorized by law)

• Preventing or reducing a serious threat to anyone’s health or safety

• Do research: We can use or share your information for health research in certain circumstances. All research projects are subject to a special approval process. We will only use or share your information for research as permitted by law (for example, if you give your consent or if an institutional review board has approved the research and privacy protections are in place).

• Comply with the law: We will share information about you if state or federal laws require it. This includes sharing information with the U.S. Department of Health and Human Services if it needs to confirm that we are complying with federal privacy laws.

• Respond to organ and tissue donation requests: If you are an organ donor, we can share health information about you with organ procurement organizations or similar entities involved in the donation and transplantation process.

• Work with a medical examiner or funeral director: In the unfortunate event of your death, we may share your health information with a coroner, medical examiner, or funeral director as necessary for them to carry out their duties (for example, to determine the cause of death or as needed to prepare for burial).

• Address workers’ compensation, law enforcement, and other government requests: We can use or share health information about you in these situations as required or permitted by law:

• Workers’ compensation: For processing claims under workers’ compensation or similar programs providing benefits for work-related injuries or illness.
• Law enforcement: To assist law enforcement officials with law enforcement purposes, such as reporting certain types of wounds or responding to a valid subpoena or court order, or to help locate a suspect, fugitive, material witness, or missing person.
• Health oversight activities: To agencies responsible for overseeing the health care system, for activities authorized by law, such as audits, inspections, or licensure investigations.
• Special government functions: For specialized government or military purposes, such as disclosures to military command authorities if you are a member of the armed forces, to authorized federal officials for national security and intelligence activities, or to protect the President and other officials.

• 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, discovery request, or other lawful process if certain conditions are met. We will only share information to the extent authorized or required by law.

Other uses of your health information: Uses and disclosures of your health information that are not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you authorize us to use or disclose your information for a purpose not described in this Notice, you may revoke that authorization at any time, in writing. If you revoke your authorization, we will no longer use or share your information for that purpose, except where we have already acted based on your permission.

Our Responsibilities

We take our responsibilities to protect your privacy very seriously. Below are some of our duties under the law and what they mean for you:

• We are required by law to maintain the privacy and security of your protected health information. We will do so, and we will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We will follow the duties and privacy practices described in this Notice and give you a copy of it. You can be confident that we will not use or share your information other than as described here unless you tell us we can in writing. If we do need to use or share your information for a purpose not covered in this Notice, we will first obtain your written authorization.

• We will not retaliate against you for exercising any of your rights or choices described in this Notice. This includes your right to file a complaint if you believe your privacy rights have been violated. We support your right to protect your privacy.

Changes to This Notice

We reserve the right to change the terms of this Notice and our privacy practices at any time, as long as such changes are permitted by law. We reserve the right to make the revised or changed Notice effective for all health information we already have about you, as well as any information we receive in the future.

If we make significant changes to our privacy practices, we will promptly update this Notice. The new Notice will be available upon request, in our office, and on our website (if we maintain one). We will also post the revised Notice in a clear and prominent location where we provide care. The Effective Date at the top will change to let you know when the Notice was last revised. You are entitled to a copy of the Notice currently in effect at any time.

Questions and Complaints

If you have any questions about this Notice or our privacy practices, or if you believe your privacy rights have been violated, you can contact us at any time.

Privacy Contact:

Shirel Ben Hayun,

HR Manager

BK Healthcare Management LLC

1649 61^st St

Ste 301, 3^rd Fl

Brooklyn, NY, 11204

Phone: 212-481-4040

Email: info@bkbehavior.com

You can file a complaint directly with us by contacting the Privacy Officer listed above. We will address your concerns and will not penalize or retaliate against you in any way for filing a complaint.

You also have the right to file a privacy complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. If you wish to do so, you can send a letter to:

U.S. Department of Health and Human Services – Office for Civil Rights 200 Independence Avenue, S.W.

Washington, D.C. 20201

Phone: 1-877-696-6775 (toll-free)

No Retaliation: We reiterate that we will not retaliate against you for filing a complaint with us or with the Office for Civil Rights. Your privacy and your rights are important to us.

Thank you for trusting [Practice Name] with your health information. We are required by law to provide you with this Notice and to abide by it. We encourage you to ask questions and seek clarification about anything you do not understand in this Notice. Your understanding of our privacy practices is important to us, and we are here to help.

Effective Date of Current Notice: [Effective Date] (This Notice remains in effect until it is replaced or updated.)