Privacy Policy

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 is intended to inform you about our practices related to your medical records, lt will explain how Arch City Foot & Ankle may use and disclose your medical information, our obligations related to the use and disclosure of your medical information, and your rights related to any medical information that we have about you. We have listed some of the reasons why we might use or disclose your medical information with some examples. Not every potential use or disclosure is discussed, but all of the ways that we are allowed to use and disclose information falls into one of the categories below. Use and Disclosure of Medical lnformation:

For Treatment: To provide you with medical treatment or services, we may need to use or disclose information about you to personnel involved in your treatment. For example, a physician may need to consult with another provider regarding your condition while providing care.

For Payment: We may use and disclose your medical information to bill and receive payment for the treatment that you received. For example, we may use or disclose your medical information to your insurance company about a service you received from Arch City

Foot & Ankle so that your insurance company can pay us or reimburse you for the service.

For Health Care Operations:

We can use and disclose medical information about you for our operations. For example, we may use or disclose medical information about you to evaluate our staffs’ performance in caring for you.

Uses and Disclosure of Medical lnformation that Do Not Require Your Authorization:

We can use or disclose health information about you without your authorization when there is an emergency, when we are required by law to treat you, or when we are required by law to use or disclose certain information. We may use or disclose your health information without your authorization in any of the following circumstances: .

When it is required by federal, state or other law; .

When it ls needed for public health activities; .

When reporting information about victims of abuse, neglect, or domestic violence.

When disclosing information for the purpose of health oversight activities; .

When disclosing information for judicialand administrative proceedings; .

When disclosing information for law enforcement purposes; .

When disclosing information about deceased persons to medicalexaminers, coroners and funeral directors; .

When disclosing or using information for organ and tissue donation purposes; .

When disclosing information for research purposes; .

When we believe in good faith that the disclosure is necessary to avert a serious health or safety threat;

When disclosure is necessary for specialized government functions; .

When disclosure is necessary to comply with worker’s compensation laws or purposes,

Planned Uses or Disclosures

We may use or disclose your health information for any of the purposes described in this section unless you affirmatively object to or othenrvise restrict a particular release. You may direct your objections or restrictions in writing to the office where you received this Notice. .

We may use or disclose your health information to contact you and remind you about an appointment for treatment or medical care. . We may use or disclose your health information to provide you with information about or recommendations of possible treatment options or alternatives that may interest you. Planned Uses or Disclosures (continued) ,

We may release health information about you to a friend and/or family member who is involved in your care.

We can tell your family and/or friends of your condition and that you are using Arch City Foot & Ankle for treatment or services,

We can also give this information to someone who will help or is helping to pay for your care. .

We can disclose health information about you to a public or private entity that is authorized by law or its charter to assist in disaster relief effotls (e.9., the American Red Cross).

Other Uses or Disclosures lf you provide us written authorization to use or disclose your health information, you can change your mind and revoke your authorization at any time, as long as you revoke your authorization in writing. lf you revoke your authorization, we will no longer use or disclose the information, but we will not be able to take back any disclosures that we have already made.

SMS consent is not shared with third parties

Your Rights with Respect to Health Information .

Right to Inspect and Copy Your Health lnformation: You have the right to inspect and copy your health information, with certainexceptions. lf you request copies of information, we may charge a fee for costs associated with your request, including the cost of copies, mailing or other supplies. .

Right to Request Information in Cerlain Form and Location: You have the right to request health information in a certain form or at a specific location. For instance, you can request that we not contact you at work. The request must tell us how and/or where you want to receive Information. We will accommodate reasonable requests. .

Right to Request Amendment to Your Health luformation: You have a right to request that your health information be amended if you believe that it is incorrect or incomplete. You must provide the reason that you want the amendment added to your health information. Your request must be in writing. .

Right to an Accounting of Disclosures: You have the right to receive an accounting of disclosures of medical information that we have made with some exceptions. You have the right to receive one (1) free accounting every twelve (12) months. lf you request more than one (‘i)accounting in any twelve (12) month period, we may charge you a reasonable fee for the costs of providing that Iist. .

Right to Request Restrictions: You have the right to request that we restrict any use or disclosure of your neattfr information. lf we agree to your restriction, we will comply with your request. For example, a patient who does not want his or her physician to share health information with other physicians involved in his or her care may request to restrict such disclosure. We are not required to accept any restriction that you request.

Federal law gives all patients a right to a paper copy of this Notice. lf you have agreed to receive this Notice in another form, you can still request a paper copy of this Notice. To obtain a paper copy of the Notice or to submit a written request related to “YoLrr Rights” contact the office where you received this Notice.

Privacy Complaints

lf you have any questions about the content of this Notice, of if you need to contact someone regarding the privacy of your health information, please contact:

Privacy Officer Arch City Foot & Ankle 1 Hilltop Village Center Dr. Eureka, MO. 63025

You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint with eitherArch City Foot & Ankle or the U.S. Department of Health and Human Services. Changes to This Notice We reserve the right to change or modify the information contained in this Notice. Any changes that we make will comply with appropriate federal, state or other laws. Arch City Foot & Ankle will provide its patients with the most recent copy of this Notice and post this version at our facilities. You can also call or write the Privacy Officer to obtain the most recent version of this Notice.

SMS Terms and Conditions:

SMS/Text Messaging Consent & Terms and Conditions– Arch City Foot & Ankle

Patient Name: ______________________________ Mobile Phone Number (required): ______________________________ (Format: (XXX) XXX-XXXX – This is the number we’ll text.)

☐ I consent to receive text messages from Arch City Foot & Ankle for non-emergency patient care communications (appointment reminders, scheduling, follow-ups, billing, test results, etc.).

I understand:

• Texts are not encrypted and carry some security risk.
• SMS consent is not shared with third parties
• Standard carrier message/data rates may apply—I’m responsible for charges.
• I can stop anytime by replying “STOP,” calling, or notifying the office in writing.
• For emergencies, call the office directly. No marketing texts.
• Messaging frequency may vary.
• Message and data rates may apply.
• To opt out at any time, text STOP.
• Mobile opt-in, SMS consent, and phone numbers will not be shared with third parties or affiliates for marketing purposes
• For assistance, text HELP or visit our website at https://www.feetdoc.com.
• Visit https://www.feetdoc.com/wp-content/uploads/2026/02/NOTICE-OF-PRIVACY-PRACTICES-2026.pdf for the privacy policy

By checking the box and submitting, I give my consent.

Electronic Signature (type name): ______________________________ Date: ________________________