Notice of Privacy Practices

Effective: [29/10/2025]

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Siya Healthcare, PLLC (“Siya Healthcare” or “Practice”) is required by law to maintain the privacy of your protected health information (“PHI”) and to provide you with this Notice of Privacy Practices (“Notice”) of its legal duties and privacy practices with respect to your PHI. Siya Healthcare is required to abide by the terms of the privacy notice currently in effect. Siya Healthcare reserves the right to change the terms of this Notice for all records and will inform you by posting the revised notice on our website or by providing it to you in the same manner this Notice was provided to you.

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Uses and Disclosures

Siya Healthcare is permitted to use and disclose your PHI for treatment, payment, and health care operations of the Practice:

• Treatment: Siya Healthcare may use and disclose your PHI to provide and coordinate the treatment, medications, and services you receive, including telehealth services. For example, we may disclose your PHI to physicians, pharmacists, or other persons involved in your care. We may disclose your PHI with other third parties, such as hospitals, other pharmacies, and other healthcare facilities and agencies to facilitate the provision of health care services, medication, and equipment you may need. This helps coordinate your care to ensure all your providers involved in your case have the information they need to meet your needs.

• Payment: Siya Healthcare may use your PHI to bill and process payment for your healthcare services. We may also disclose your PHI to other healthcare providers or HIPAA-covered entities who may need it for their payment activities.

• Healthcare Operation: Siya Healthcare may disclose your health information to another entity with which you have or had a relationship if that entity requests your information for certain of its healthcare operations or we may disclose your PHI to review treatment and services to evaluate the performance of our staff and for other management and administrative purposes. We may also disclose your PHI to other HIPAA-covered entities that have provided services to you so that they can improve the quality and effectiveness of the healthcare services that they provide. We may use your PHI to create de-identified data, which is stripped of your identifiable data and no longer identifies you.

 

Siya Healthcare may also use or disclose your PHI incident to a permitted use or disclosure. For example, we may use your PHI to remind you of services scheduled to be received, to inform you about possible treatment alternatives, or health-related benefits and services that may be of interest to you. We may also contact you for fundraising unless you opt out of receiving fundraising solicitations.

The Practice will also share and disclose your PHI with third-party “Business Associates” which perform various activities on our behalf (for example, billing, collections, and network and software services). This includes communication with patients or person(s) identified as point of contact, as well as other healthcare professionals. Siya Healthcare will take every precaution to prevent disclosure without authorization or consent, including using encrypted email accounts.

 

Disclosures Without Your Authorization

1. As Required By Law: We will use and disclose your PHI as required by law but will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect, or domestic violence, respond to judicial or administrative proceedings, or to law enforcement officials, we will comply with the requirements concerning those activities.

2. Public Health Activities: We may disclose your information to public health authorities to prevent or control disease, infection, injury, or disability. We may also be required to disclose your information for reporting problems with products and reactions to medications to the Food and Drug Administration.

3. Reporting Victims of Abuse, Neglect, or Domestic Violence: If we believe that you have been a victim of abuse, neglect, or domestic violence, we may use and disclose your PHI to notify a government authority if authorized by law.

4. Health Oversight Activities: We may disclose your PHI to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure actions or for activities involving government oversight of the healthcare system.

5. To Avert a Serious Threat to Health or Safety: When necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person, we may use or disclose PHI and limit such disclosures to those able to help lessen or prevent the threatened harm.

6. Judicial and Administrative Proceedings: We may disclose your PHI in the course of any administrative order or in response to a subpoena or other lawful processes.

7. Law Enforcement: We may disclose your PHI to law enforcement officials for purposes such as identifying or locating a suspect, fugitive, material witness, or missing person, complying with a court order, warrant, or grand jury subpoena.

8. Research: We may use and disclose your PHI to researchers if an institutional review board has approved such use and disclosures, ensuring adequate safeguards have been taken to protect your PHI.

9. Coroners, Medical Examiners, Funeral Directors: We may disclose your PHI to coroners, medical examiners, and funeral directors to fulfill their duties.

10. Organ and Tissue Donation: We may disclose your PHI to organizations involved in procuring, banking, or transplanting organs and tissues.

11. Specific Government Functions: We may disclose your PHI to military officials if you are an active member of the military or to determine eligibility and/or benefits for veterans. We may also disclose your PHI for national security, intelligence activities, the protection of the President, and to determine officials’ suitability to serve in public office.

12. Workers' Compensation: We may disclose your PHI as authorized to comply with workers' compensation laws or similar programs that provide benefits for work-related injuries or illnesses.

13. Notification and Communication with Family: We may disclose your PHI to notify or assist in notifying a family member, personal representative, or another person responsible for your care. We may disclose your PHI to individuals involved in your care or responsible for paying for your care.

 

Disclosures Made Only With Your Written Authorization

Other uses and disclosures of your PHI will be made only with your written authorization unless otherwise permitted or required by law as described in this Notice. These uses and disclosures include most uses and disclosures of psychotherapy notes (where applicable), marketing purposes, and disclosures that constitute a sale of your PHI.

 

Individual Rights

1. Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your PHI. We reserve the right to accept or reject your request.

2. Right to Inspect and Copy: You have the right to inspect and copy your records with limited exceptions.

3. Request Amendment: You may request changes to your PHI by submitting a written request.

4. Request an Accounting of Disclosures: You may request an accounting of certain disclosures of your PHI that we have made.

5. Request a Paper Copy of This Notice: You may request a paper copy of this Notice at any time.

6. Request Confidential Communications: You may request that you receive your PHI in a specific way or at a specific location.

 

Complaints and Contact

If you believe your privacy rights have been violated, you may make a written complaint by delivery to the Practice, State Medical Board, or the Secretary of HHS. You will not be retaliated against if you file a complaint. You may also request additional information by written request to:

 

Siya Healthcare, PLLC

3129 Kingsley Dr Ste 1940, Pearland, TX, US

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HIPAA Privacy Notice and Consent

I acknowledge that I have received the Notice of Privacy Practices, which outlines how my protected health information (PHI) may be used and disclosed by the Provider. I understand my rights regarding the privacy of my PHI and consent to its use and disclosure as described in the Notice of Privacy Practices.

Acknowledgment of Receipt

I, ___________________________ (individual's name), acknowledge that on _________________________ (date), I received a copy of Siya Healthcare’s Notice of Privacy Practices and that I read and understood it. I understand that:

• I have certain rights to privacy regarding my PHI.

• Siya Healthcare can and will use my PHI for purposes of my treatment, payment, and health care operations.

• The Notice explains in more detail how Siya Healthcare may use and share my PHI for other purposes.

• I have the rights regarding my PHI listed in the Notice.

• Siya Healthcare has the right to change the Notice from time to time and I can obtain a current copy of the Notice by contacting [marketing@siya.health].

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Signature

_____________________________________________________

Printed Name

Date:_____________________________________________________

Date of Birth:_____________________________________________________

Relationship to Patient: _____________________________________________________

 

Please retain a copy of this consent form for your records. If you have any questions or concerns about telehealth or the information provided in this form, please do not hesitate to contact Siya Healthcare at [marketing@siya.health].