NOTICE OF PRIVACY PRACTICES AND POLICIES

effective Apr 1st, 2026

AS REQUIRED BY FEDERAL LEGISLATION, THIS NOTICE DESCRIBES HOW HEALTHCARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice applies to all of the paper and electronic records of your care maintained by Sara Clark MD PLLC (DBA: Manifold Psychiatry), whether created by the doctors, clinic personnel, or records acquired from outside resources such as other clinicians involved in your care and laboratory reports.

WAYS THE PRACTICE MAY USE AND DISCLOSE YOUR INFORMATION

The following categories describe ways that we use and share your confidential information. Confidential information includes Protected Health Information (PHI) (information that could be used to identify you). Not every use or disclosure in a category is listed. However, all of the ways we are permitted to use and disclose information will fall within one of the following categories.

A. DISCLOSURES WHICH REQUIRE AUTHORIZATION

Psychotherapy notes are handled separately under HIPAA and have additional protections. Specifically, the regulations state that in most instances a practice must obtain an authorization for any use or disclosure of psychotherapy notes. No authorization is needed to carry out treatment, payment, healthcare operations, or the uses listed in routine situations. All other circumstances require a valid authorization from you for use and disclosure.

Confidential information may be released for payment and healthcare operations only to health insurance plans and their agents, as well as business associates of the practice. The definition of a health insurance plan does not include life insurance companies, automobile insurance companies, or workers’ compensation carriers. These are not covered under HIPAA. If you would like information submitted to one of these companies, an authorization will be required, unless it is already mandated by state or federal law.

B. ROUTINE SITUATIONS

1. For Treatment Sara Clark MD PLLC (DBA: Manifold Psychiatry) may use information about you in order to provide you with proper medical treatment or services. Treatment is when we provide, coordinate, or manage your healthcare and other services related to your healthcare. An example of treatment is when the provider consults with another healthcare provider, such as your primary care physician.

2. For Payment Sara Clark MD PLLC (DBA: Manifold Psychiatry) may use and disclose information about you so that the treatment and services you receive may be billed and payment can be collected from you, an insurance company, or a third party (including a collection agency if necessary). For example, practice may give your health insurance plan information about services you received at the practice, so your health insurance can pay Sara Clark MD PLLC (DBA: Manifold Psychiatry) or reimburse you for the services. We may also tell your health insurance plan about a treatment you are going to receive, in order to obtain prior approval or determine if your plan will cover the treatment.

3. For Healthcare Operations Sara Clark MD PLLC (DBA: Manifold Psychiatry) may use and share information about you for administrative functions necessary to run the practice and promote quality care. We may share information with business associates who provide services necessary to run the practice, such as transcription companies or billing services. Sara Clark MD PLLC (DBA: Manifold Psychiatry) will contractually bind these third parties to protect your information as we would ourselves. Also, we may permit your health insurance plan or other providers, such as life insurance and disability insurance companies, to review records that contain information about you to assist them in improving the quality of service provided to you.

4. Communicating with You and Others Involved in Your Care Sara Clark MD PLLC (DBA: Manifold Psychiatry) may contact you to provide appointment reminders, information about treatment alternatives, or other health related benefits and services that may be of interest to you. In certain situations, we may share information about you with a friend or family member who is involved in your care or payment for your care unless you have requested that such disclosures not occur and Sara Clark MD PLLC (DBA: Manifold Psychiatry) has agreed. Information disclosed will be directly relevant to such person’s involvement with your care or payment related to your care. Whenever possible, this person will be identified by you. However, in emergencies or other situations in which you are unable to indicate your preference, Sara Clark MD PLLC (DBA: Manifold Psychiatry) may need to share information about you with other individuals or organizations to coordinate your care or notify your family.

C. SPECIAL SITUATIONS

1. As Required By Law: Sara Clark MD PLLC (DBA: Manifold Psychiatry) will disclose information about you when required to do so by federal, state or local law. For example, Sara Clark MD PLLC (DBA: Manifold Psychiatry) may release information about you in response to a valid court subpoena or for communicable disease reporting.

2. Health Oversight Activities: DSara Clark MD PLLC (DBA: Manifold Psychiatry) may disclose information to a health oversight agency for activities authorized by law. For example, these oversight activities include: audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.

3. For Judicial or Administrative Proceedings: If you are involved in a court proceeding, and a request is made for information about the professional services that you have received within my practice and the records thereof, such information may be privileged under state law. Sara Clark MD PLLC (DBA: Manifold Psychiatry) will not release information without the written authorization of you or your legal representative, or in instance of issuance. This may also be the case in the instance of a court subpoena, which requires the provision of such information, which you have been properly notified. In response, you have not opposed the court subpoena within the legally specified format and timeframe, or in the instance of the issuance of a court order compelling me to provide Protected Health Information (PHI). This privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.

4. To Avert Serious Threat to Health or Safety: Sara Clark MD PLLC (DBA: Manifold Psychiatry) may disclose your confidential mental health information to any person without authorization if we reasonably believe that disclosure will avoid or minimize imminent danger to your health or safety, or the health or safety of any other individual. These disclosures may be to law enforcement officials to respond to a violent crime or to protect the target of a violent crime. For example, threats of harming another individual may be reported to appropriate authorities.

5. Worker’s Compensation: If you file a worker's compensation claim, with certain exceptions, Sara Clark MD PLLC (DBA: Manifold Psychiatry) must make available at any stage of the proceedings, all PHI information in our possession that is relevant to that particular injury in the opinion of the Washington State Department of Labor and Industries, to your employer, your representative, and the Department of Labor and Industries upon request.

6. Public Health Risks: Sara Clark MD PLLC (DBA: Manifold Psychiatry) may disclose information about you for public health activities. These activities generally include, but are not limited to, the following:

a. To prevent or control disease, injury, or disability

b. To report child abuse or neglect

c. To report adult and domestic abuse

d. To report reactions to medications or problems with products

e. To notify people of recalls of products they may be using

f. To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition

g. To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

7. Law Enforcement: Sara Clark MD PLLC (DBA: Manifold Psychiatry) may release information about you if asked to do so by a law enforcement official:

a. In response to a court order, subpoena, warrant, summons, or similar process

b. To identify or locate a suspect, fugitive, material witness, or missing person

c. If you are suspected to be a victim of a crime, generally with your permission

d. About a death we believe may be the result of criminal conduct

e. About criminal conduct at the hospital

f. In emergency circumstances, to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

g. In the event of Medical Emergency

h. In the event of the client’s death or disability, information may be released if the client’s personal representative or the beneficiary of an insurance policy on the client’s life signs a release authorizing disclosure

To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.

YOUR RIGHTS AS A PATIENT

In addition to provisions by the practice to protect your confidential information, you are entitled to six (6) specific rights as a patient.

1. You have the right to request restrictions on certain uses and disclosures. You have the right to request a restriction or limitation on the use and sharing of information about you for treatment, payment, administrative functions, or with individuals involved in your care. To request restrictions, you must make your request in writing to Sara Clark MD PLLC (DBA: Manifold Psychiatry). In your request, you must specify: (1) what information you want to limit; (2)whether you want to limit use, disclosure, or both; and (3) to whom you want it to apply. Sara Clark MD PLLC (DBA: Manifold Psychiatry) is not required to agree to your request. If Sara Clark MD PLLC (DBA: Manifold Psychiatry) agrees, we will comply with your request unless the information is needed to provide you with emergency treatment.

2. You have the right to receive confidential communications. You have the right to request that Sara Clark MD PLLC (DBA: Manifold Psychiatry) communicates with you in a certain way or at a certain location. For example, you can ask that we only contact you at work or at a post office box. To request confidential communications, you must make your request in writing to Sara Clark MD PLLC (DBA: Manifold Psychiatry). Your request must specify how or where you wish to be contacted. Sara Clark MD PLLC (DBA: Manifold Psychiatry) will not ask you for the reason and will seek to accommodate all reasonable requests.

3. You have the right to inspect and obtain copies. You have the right to review and obtain copies of information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes, information compiled in reasonable anticipation of a legal action or proceeding; and confidential information related to certain laboratory tests under Clinical Laboratory Improvement Amendments (CLIA). To inspect and copy information that may be used to make decisions about you, you must submit your request to Sara Clark MD PLLC (DBA: Manifold Psychiatry) in writing. You may be charged a fee for the costs of copying, mailing or other supplies associated with your request. Under limited circumstances, Sara Clark MD PLLC (DBA: Manifold Psychiatry) may deny access to your records if Sara Clark MD PLLC (DBA: Manifold Psychiatry) believes the information may be harmful to you or someone else. You have the right to appeal any denials. The appeal will be reviewed by a qualified individual other than myself. Sara Clark MD PLLC (DBA: Manifold Psychiatry) will comply with the outcome of the review.

4. You have the right to amend confidential information. If you feel that the information Sara Clark MD PLLC (DBA: Manifold Psychiatry) has about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Sara Clark MD PLLC (DBA: Manifold Psychiatry). To request an amendment, your request and a reason that supports your request, must be made in writing and submitted to Sara Clark MD PLLC (DBA: Manifold Psychiatry). We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, Sara Clark MD PLLC (DBA: Manifold Psychiatry) may deny your request if you ask us to amend information that:

a. Was not created by Sara Clark MD PLLC (DBA: Manifold Psychiatry), unless the person or entity that created the information is no longer available to make the amendment. In such instances Sara Clark MD PLLC (DBA: Manifold Psychiatry) would consider the request

b. Is not part of the information kept by or for Sara Clark MD PLLC (DBA: Manifold Psychiatry)

c. Is not part of the information which you would be permitted to inspect and copy

d. Is accurate and complete

5. You have the right to receive an accounting of disclosures of confidential information. You may ask to receive an accounting of certain disclosures made about you that were not related to the routine uses listed above. To request this list or accounting of disclosures, you must submit your request in writing to Sara Clark MD PLLC (DBA: Manifold Psychiatry). Your request must state a time period that may not be longer than six (6) years. Sara Clark MD PLLC (DBA: Manifold Psychiatry) will notify you of the estimated cost involved and you may choose to withdraw or modify your requests because any costs are incurred. Disclosures do not have to be made when those disclosures are:

a. To carry out treatment, payment and healthcare operations

b. To individuals of confidential information about them

c. As a result of assigned authorization

d. For the practice’s directory or to persons involved in your care

e. For national security or intelligence purposes; or

f. To correctional institutions or law enforcement officials

In all cases, including those listed above, if we have substance use disorder patient records about you, subject to 42 CFR part 2, we cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your consent or (2) a court order and a subpoena.

6. You have the right to obtain a paper copy of this Notice upon request. Even if you have requested an electronic copy, Sara Clark MD PLLC (DBA: Manifold Psychiatry) will provide you with a paper copy of this Notice at your request.

If we have your substance use disorder patient records, subject to 42 CFR part 2, we will give you clear and obvious notice in advance and a choice about whether to receive fundraising communications that use your Part 2 information.

Sara Clark MD PLLC (DBA: Manifold Psychiatry) Duties

In addition to your rights as a patient, Sara Clark MD PLLC (DBA: Manifold Psychiatry) has duties to protect your confidential information and inform you of changes to protection measures. Sara Clark MD PLLC (DBA: Manifold Psychiatry) is required by law to maintain the privacy of confidential information and provide you with notice of our legal duties and privacy practices with respect to such information. Sara Clark MD PLLC (DBA: Manifold Psychiatry) is required to abide by the terms of this Notice currently in effect.

Changes to this notice
Sara Clark MD PLLC (DBA: Manifold Psychiatry) reserves the right to revise or change provisions on this Notice. Sara Clark MD PLLC (DBA: Manifold Psychiatry) will make the new Notice provisions effective for all confidential information we maintain. Sara Clark MD PLLC (DBA: Manifold Psychiatry) will promptly revise and distribute the Notice whenever there is a change to the uses or disclosures, your rights, and our duties, or other privacy practices stated in this Notice. Sara Clark MD PLLC (DBA: Manifold Psychiatry) will provide updates of the notice to all active patients. Patients who are inactive at the time of mailing may receive an updated copy at their next scheduled appointment. A copy of the current Notice will be available throughout the practice. The Notice will contain the effective date on the top of first page.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with Sara Clark MD PLLC (DBA: Manifold Psychiatry) or with the Secretary of the Department of Health and Human Services. All complaints must be submitted or verified in writing. You have specific rights under the Privacy Rule. You will not be penalized for filing a complaint.

Other uses of information

Other uses and disclosures of information not covered by this notice or the laws that apply to my practice will be made only with your written permission. If you provide my practice with specific permission to use or disclose information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, Sara Clark MD PLLC (DBA: Manifold Psychiatry) will no longer use or disclose information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures that have already been made with your permission and that Sara Clark MD PLLC (DBA: Manifold Psychiatry) is required to retain our records of the care that we provided to you.

Privacy Officer

Sara Clark is the privacy officer for Sara Clark MD PLLC (DBA: Manifold Psychiatry). You may contact her with any questions or comments.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE

I am required to provide you with a copy of this Notice and document your receipt.

In order to comply with HIPAA standards each practice must obtain a signed acknowledgement that each direct treatment patient has received its Notice of Privacy Practices or must document a good faith effort to provide the Notice and receive a written acknowledgement of receipt. This will allow practices to use or disclose confidential information (protected health information) for treatment, payment, or health care operations.

I have received a copy of the Notice of Privacy Practices from: Sara Clark MD PLLC (DBA: Manifold Psychiatry)