Privacy Policy

Privacy Policy

Last updated October 08, 2026

This Privacy Notice for Apple Ridge Family Medicine/Evergreen Adult Medicine (doing business as Evergreen TRT) ("we," "us," or "our"), describes how and why we might access, collect, store, use, and/or share ("process") your personal information when you use our services ("Services"), including when you:

• Visit our website at https://www.evergreentrt.com or any website of ours that links to this Privacy Notice
• Engage with us in other related ways, including any marketing or events

Questions or concerns? Reading this Privacy Notice will help you understand your privacy rights and choices. We are responsible for making decisions about how your personal information is processed. If you do not agree with our policies and practices, please do not use our Services. If you still have any questions or concerns, please contact us at [email protected].

Summary of Key Points

This summary provides key points from our Privacy Notice, but you can find out more details about any of these topics by clicking the link following each key point or by using our table of contents below to find the section you are looking for.

What personal information do we process? When you visit, use, or navigate our Services, we may process personal information depending on how you interact with us and the Services, the choices you make, and the products and features you use. Learn more about personal information you disclose to us.

Do we process any sensitive personal information? Some of the information may be considered "special" or "sensitive" in certain jurisdictions, for example your racial or ethnic origins, sexual orientation, and religious beliefs. We may process sensitive personal information when necessary with your consent or as otherwise permitted by applicable law. Learn more about sensitive information we process.

Do we collect any information from third parties? We may collect information from public databases, marketing partners, social media platforms, and other outside sources. Learn more about information collected from other sources.

How do we process your information? We process your information to provide, improve, and administer our Services, communicate with you, for security and fraud prevention, and to comply with law. We may also process your information for other purposes with your consent. We process your information only when we have a valid legal reason to do so. Learn more about how we process your information.

In what situations and with which parties do we share personal information? We may share information in specific situations and with specific third parties. Learn more about when and with whom we share your personal information.

How do we keep your information safe? We have adequate organizational and technical processes and procedures in place to protect your personal information. However, no electronic transmission over the internet or information storage technology can be guaranteed to be 100% secure, so we cannot promise or guarantee that hackers, cybercriminals, or other unauthorized third parties will not be able to defeat our security and improperly collect, access, steal, or modify your information. Learn more about how we keep your information safe.

What are your rights? Depending on where you are located geographically, the applicable privacy law may mean you have certain rights regarding your personal information. Learn more about your privacy rights.

How do you exercise your rights? The easiest way to exercise your rights is by visiting https://forms.monday.com/forms/df847b6311d6d81090b54b314da7ae6d?r=use1, or by contacting us. We will consider and act upon any request in accordance with applicable data protection laws.

Want to learn more about what we do with any information we collect? Review the Privacy Notice in full.

1. What Information Do We Collect?

Personal information you disclose to us

In Short: We collect personal information that you provide to us.

We collect personal information that you voluntarily provide to us when you express an interest in obtaining information about us or our products and Services, when you participate in activities on the Services, or otherwise when you contact us.

Personal Information Provided by You. The personal information that we collect depends on the context of your interactions with us and the Services, the choices you make, and the products and features you use. The personal information we collect may include the following:

• names
• phone numbers
• email addresses
• mailing addresses
• contact preferences
• billing addresses
• debit/credit card numbers

Sensitive Information. When necessary, with your consent or as otherwise permitted by applicable law, we process the following categories of sensitive information:

• health data

Payment Data. We may collect data necessary to process your payment if you choose to make purchases, such as your payment instrument number, and the security code associated with your payment instrument. All payment data is handled and stored by Fluidpay. You may find their privacy notice link(s) here: https://www.fluidpay.com/privacy-policy.

All personal information that you provide to us must be true, complete, and accurate, and you must notify us of any changes to such personal information.

Google API

Our use of information received from Google APIs will adhere to Google API Services User Data Policy, including the Limited Use requirements.

Information collected from other sources

In Short: We may collect limited data from public databases, marketing partners, and other outside sources.

In order to enhance our ability to provide relevant marketing, offers, and services to you and update our records, we may obtain information about you from other sources, such as public databases, joint marketing partners, affiliate programs, data providers, and from other third parties. This information includes mailing addresses, job titles, email addresses, phone numbers, intent data (or user behavior data), Internet Protocol (IP) addresses, social media profiles, social media URLs, and custom profiles, for purposes of targeted advertising and event promotion.

2. How Do We Process Your Information?

In Short: We process your information to provide, improve, and administer our Services, communicate with you, for security and fraud prevention, and to comply with law. We may also process your information for other purposes with your consent.

We process your personal information for a variety of reasons, depending on how you interact with our Services, including:

• To send you marketing and promotional communications. We may process the personal information you send to us for our marketing purposes, if this is in accordance with your marketing preferences. You can opt out of our marketing emails at any time. For more information, see "WHAT ARE YOUR PRIVACY RIGHTS?" below.
• To deliver targeted advertising to you. We may process your information to develop and display personalized content and advertising tailored to your interests, location, and more.

3. When and With Whom Do We Share Your Personal Information?

In Short: We may share information in specific situations described in this section.

We may need to share your personal information in the following situations:

• Business Transfers. We may share or transfer your information in connection with, or during negotiations of, any merger, sale of company assets, financing, or acquisition of all or a portion of our business to another company.
• When we use Google Maps Platform APIs. We may share your information with certain Google Maps Platform APIs (e.g., Google Maps API, Places API). Google Maps uses GPS, Wi-Fi, and cell towers to estimate your location. GPS is accurate to about 20 meters, while Wi-Fi and cell towers help improve accuracy when GPS signals are weak, like indoors. This data helps Google Maps provide directions, but it is not always perfectly precise.
• Business Partners. We may share your information with our business partners to offer you certain products, services, or promotions.

4. Do We Use Cookies and Other Tracking Technologies?

In Short: We may use cookies and other tracking technologies to collect and store your information.

We may use cookies and similar tracking technologies (like web beacons and pixels) to gather information when you interact with our Services. Some online tracking technologies help us maintain the security of our Services, prevent crashes, fix bugs, save your preferences, and assist with basic site functions.

We also permit third parties and service providers to use online tracking technologies on our Services for analytics and advertising, including to help manage and display advertisements or to tailor advertisements to your interests. The third parties and service providers use their technology to provide advertising about products and services tailored to your interests which may appear either on our Services or on other websites.

To the extent these online tracking technologies are deemed to be a "sale"/"sharing" (which includes targeted advertising, as defined under the applicable laws) under applicable US state laws, you can opt out of these online tracking technologies by submitting a request as described below under section "DO UNITED STATES RESIDENTS HAVE SPECIFIC PRIVACY RIGHTS?"

You can learn how to refuse or remove cookies in the section "WHAT ARE YOUR PRIVACY RIGHTS?" below.

Google Analytics

We may share your information with Google Analytics to track and analyze the use of the Services. The Google Analytics Advertising Features that we may use include: Remarketing with Google Analytics, Google Display Network Impressions Reporting and Google Analytics Demographics and Interests Reporting. To opt out of being tracked by Google Analytics across the Services, visit https://tools.google.com/dlpage/gaoptout. You can opt out of Google Analytics Advertising Features through Ads Settings and Ad Settings for mobile apps. Other opt out means include http://optout.networkadvertising.org/ and http://www.networkadvertising.org/mobile-choice. For more information on the privacy practices of Google, please visit the Google Privacy & Terms page.

5. Do We Offer Artificial Intelligence-Based Products?

In Short: We offer products, features, or tools powered by artificial intelligence, machine learning, or similar technologies.

As part of our Services, we offer products, features, or tools powered by artificial intelligence, machine learning, or similar technologies (collectively, "AI Products"). These tools are designed to enhance your experience and provide you with innovative solutions. The terms in this Privacy Notice govern your use of the AI Products within our Services.

Our AI Products

Our AI Products are designed for the following functions:

• AI bots

How We Process Your Data Using AI

All personal information processed using our AI Products is handled in line with our Privacy Notice and our agreement with third parties. This ensures high security and safeguards your personal information throughout the process, giving you peace of mind about your data's safety.

How to Opt Out

We believe in giving you the power to decide how your data is used. To opt out, you can:

• Contact us using the contact information provided

6. How Long Do We Keep Your Information?

In Short: We keep your information for as long as necessary to fulfill the purposes outlined in this Privacy Notice unless otherwise required by law.

We will only keep your personal information for as long as it is necessary for the purposes set out in this Privacy Notice, unless a longer retention period is required or permitted by law (such as tax, accounting, or other legal requirements).

When we have no ongoing legitimate business need to process your personal information, we will either delete or anonymize such information, or, if this is not possible (for example, because your personal information has been stored in backup archives), then we will securely store your personal information and isolate it from any further processing until deletion is possible.

7. How Do We Keep Your Information Safe?

In Short: We aim to protect your personal information through a system of organizational and technical security measures.

We have implemented appropriate and reasonable technical and organizational security measures designed to protect the security of any personal information we process. However, despite our safeguards and efforts to secure your information, no electronic transmission over the Internet or information storage technology can be guaranteed to be 100% secure, so we cannot promise or guarantee that hackers, cybercriminals, or other unauthorized third parties will not be able to defeat our security and improperly collect, access, steal, or modify your information. Although we will do our best to protect your personal information, transmission of personal information to and from our Services is at your own risk. You should only access the Services within a secure environment.

8. Do We Collect Information From Minors?

In Short: We do not knowingly collect data from or market to children under 18 years of age.

We do not knowingly collect, solicit data from, or market to children under 18 years of age, nor do we knowingly sell such personal information. By using the Services, you represent that you are at least 18 or that you are the parent or guardian of such a minor and consent to such minor dependent's use of the Services. If we learn that personal information from users less than 18 years of age has been collected, we will deactivate the account and take reasonable measures to promptly delete such data from our records. If you become aware of any data we may have collected from children under age 18, please contact us at [email protected].

9. What Are Your Privacy Rights?

In Short: You may review, change, or terminate your account at any time, depending on your country, province, or state of residence.

Withdrawing your consent: If we are relying on your consent to process your personal information, which may be express and/or implied consent depending on the applicable law, you have the right to withdraw your consent at any time. You can withdraw your consent at any time by contacting us by using the contact details provided in the section "HOW CAN YOU CONTACT US ABOUT THIS NOTICE?" below.

However, please note that this will not affect the lawfulness of the processing before its withdrawal nor, when applicable law allows, will it affect the processing of your personal information conducted in reliance on lawful processing grounds other than consent.

Opting out of marketing and promotional communications: You can unsubscribe from our marketing and promotional communications at any time by replying "STOP" or "UNSUBSCRIBE" to the SMS messages that we send, or by contacting us using the details provided in the section "HOW CAN YOU CONTACT US ABOUT THIS NOTICE?" below. You will then be removed from the marketing lists. However, we may still communicate with you, for example, to send you service-related messages that are necessary for the administration and use of your account, to respond to service requests, or for other non-marketing purposes.

No mobile information will be shared with third parties or affiliates for marketing or promotional purposes. Information sharing to subcontractors in support services, such as customer service, is permitted. All other use case categories exclude text messaging originator opt-in data and consent; this information will not be shared with third parties.

Cookies and similar technologies: Most Web browsers are set to accept cookies by default. If you prefer, you can usually choose to set your browser to remove cookies and to reject cookies. If you choose to remove cookies or reject cookies, this could affect certain features or services of our Services.

If you have questions or comments about your privacy rights, you may email us at [email protected].

10. Controls for Do-Not-Track Features

Most web browsers and some mobile operating systems and mobile applications include a Do-Not-Track ("DNT") feature or setting you can activate to signal your privacy preference not to have data about your online browsing activities monitored and collected. At this stage, no uniform technology standard for recognizing and implementing DNT signals has been finalized. As such, we do not currently respond to DNT browser signals or any other mechanism that automatically communicates your choice not to be tracked online. If a standard for online tracking is adopted that we must follow in the future, we will inform you about that practice in a revised version of this Privacy Notice.

California law requires us to let you know how we respond to web browser DNT signals. Because there currently is not an industry or legal standard for recognizing or honoring DNT signals, we do not respond to them at this time.

Global Privacy Control: We recognize and honor Global Privacy Control (GPC) signals. If you use a browser or extension that supports GPC, we will treat this as a valid request to opt out of the sale or sharing of your personal information for targeted advertising purposes under applicable state privacy laws, including the California Consumer Privacy Act (CCPA). When we detect a GPC signal from your browser, we will automatically apply your opt-out preference without requiring you to take any additional action. For more information about GPC and how to enable it, visit globalprivacycontrol.org.

11. Do United States Residents Have Specific Privacy Rights?

In Short: If you are a resident of California, Colorado, Connecticut, Delaware, Florida, Indiana, Iowa, Kentucky, Maryland, Minnesota, Montana, Nebraska, New Hampshire, New Jersey, Oregon, Rhode Island, Tennessee, Texas, Utah, or Virginia, you may have the right to request access to and receive details about the personal information we maintain about you and how we have processed it, correct inaccuracies, get a copy of, or delete your personal information. You may also have the right to withdraw your consent to our processing of your personal information. These rights may be limited in some circumstances by applicable law. More information is provided below.

Categories of Personal Information We Collect

The table below shows the categories of personal information we have collected in the past twelve (12) months. The table includes illustrative examples of each category and does not reflect the personal information we collect from you. For a comprehensive inventory of all personal information we process, please refer to the section "WHAT INFORMATION DO WE COLLECT?"

We may also collect other personal information outside of these categories through instances where you interact with us in person, online, or by phone or mail in the context of:

• Receiving help through our customer support channels;
• Participation in customer surveys or contests; and
• Facilitation in the delivery of our Services and to respond to your inquiries.

Sources of Personal Information

Learn more about the sources of personal information we collect in "WHAT INFORMATION DO WE COLLECT?"

How We Use and Share Personal Information

Learn more about how we use your personal information in the section, "HOW DO WE PROCESS YOUR INFORMATION?"

Will your information be shared with anyone else?

We may disclose your personal information with our service providers pursuant to a written contract between us and each service provider. Learn more about how we disclose personal information to in the section, "WHEN AND WITH WHOM DO WE SHARE YOUR PERSONAL INFORMATION?"

We may use your personal information for our own business purposes, such as for undertaking internal research for technological development and demonstration. This is not considered to be "selling" of your personal information.

We have not disclosed, sold, or shared any personal information to third parties for a business or commercial purpose in the preceding twelve (12) months. We will not sell or share personal information in the future belonging to website visitors, users, and other consumers.

Your Rights

You have rights under certain US state data protection laws. However, these rights are not absolute, and in certain cases, we may decline your request as permitted by law. These rights include:

• Right to know whether or not we are processing your personal data
• Right to access your personal data
• Right to correct inaccuracies in your personal data
• Right to request the deletion of your personal data
• Right to obtain a copy of the personal data you previously shared with us
• Right to non-discrimination for exercising your rights
• Right to opt out of the processing of your personal data if it is used for targeted advertising (or sharing as defined under California's privacy law), the sale of personal data, or profiling in furtherance of decisions that produce legal or similarly significant effects ("profiling")

Depending upon the state where you live, you may also have the following rights:

• Right to access the categories of personal data being processed (as permitted by applicable law, including the privacy law in Minnesota)
• Right to obtain a list of the categories of third parties to which we have disclosed personal data (as permitted by applicable law, including the privacy law in California, Delaware, and Maryland)
• Right to obtain a list of specific third parties to which we have disclosed personal data (as permitted by applicable law, including the privacy law in Minnesota and Oregon)
• Right to obtain a list of third parties to which we have sold personal data (as permitted by applicable law, including the privacy law in Connecticut)
• Right to review, understand, question, and depending on where you live, correct how personal data has been profiled (as permitted by applicable law, including the privacy law in Connecticut and Minnesota)
• Right to limit use and disclosure of sensitive personal data (as permitted by applicable law, including the privacy law in California)
• Right to opt out of the collection of sensitive data and personal data collected through the operation of a voice or facial recognition feature (as permitted by applicable law, including the privacy law in Florida)

How to Exercise Your Rights

To exercise these rights, you can contact us by visiting https://forms.monday.com/forms/df847b6311d6d81090b54b314da7ae6d?r=use1, by emailing us at [email protected], or by referring to the contact details at the bottom of this document.

We will honor your opt-out preferences if you enact the Global Privacy Control (GPC) opt-out signal on your browser.

Under certain US state data protection laws, you can designate an authorized agent to make a request on your behalf. We may deny a request from an authorized agent that does not submit proof that they have been validly authorized to act on your behalf in accordance with applicable laws.

Request Verification

Upon receiving your request, we will need to verify your identity to determine you are the same person about whom we have the information in our system. We will only use personal information provided in your request to verify your identity or authority to make the request. However, if we cannot verify your identity from the information already maintained by us, we may request that you provide additional information for the purposes of verifying your identity and for security or fraud-prevention purposes.

If you submit the request through an authorized agent, we may need to collect additional information to verify your identity before processing your request and the agent will need to provide a written and signed permission from you to submit such request on your behalf.

Appeals

Under certain US state data protection laws, if we decline to take action regarding your request, you may appeal our decision by emailing us at [email protected]. We will inform you in writing of any action taken or not taken in response to the appeal, including a written explanation of the reasons for the decisions. If your appeal is denied, you may submit a complaint to your state attorney general.

12. Do We Make Updates to This Notice?

In Short: Yes, we will update this notice as necessary to stay compliant with relevant laws.

We may update this Privacy Notice from time to time. The updated version will be indicated by an updated "Revised" date at the top of this Privacy Notice. If we make material changes to this Privacy Notice, we may notify you either by prominently posting a notice of such changes or by directly sending you a notification. We encourage you to review this Privacy Notice frequently to be informed of how we are protecting your information.

13. How Can You Contact Us About This Notice?

If you have questions or comments about this notice, you may email us at [email protected] or contact us by post at:

Apple Ridge Family Medicine/Evergreen Adult Medicine
20 Frederick Road
Thurmont, MD 21788
United States

14. How Can You Review, Update, or Delete the Data We Collect From You?

Based on the applicable laws of your country or state of residence in the US, you may have the right to request access to the personal information we collect from you, details about how we have processed it, correct inaccuracies, or delete your personal information. You may also have the right to withdraw your consent to our processing of your personal information. These rights may be limited in some circumstances by applicable law. To request to review, update, or delete your personal information, please visit: https://forms.monday.com/forms/df847b6311d6d81090b54b314da7ae6d?r=use1.

Notice of Privacy Practices

Evergreen TRT
20 Frederick Rd Thurmont, MD 21788
Phone-1-877-341-1231 Fax-717-338-9070

Your Rights. Our Responsibilities.

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.

Summary

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds

Our Uses and Disclosures

We may use and share your information as we:

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

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

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 an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• 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, home, office, or cell 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 your request, and we may say “no,” for example, if it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” 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 for 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, cost-based fee if you ask for another one 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 the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If someone has authority to act as your personal representative, such as if someone has your 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 take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the contact information at the top of this notice.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html.
• We will not retaliate against you for filing 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, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care or payment for your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able 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. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

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.

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.

Example: A doctor treating you for an injury asks 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 contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

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 and research. We have to meet many conditions in the law before we can share your information for these purposes.

In all cases, including those listed below, 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.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

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.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described in this notice unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Other Instructions for Notice

• Insert Effective Date of this Notice
• Insert name or title of the privacy official (or other privacy contact) and his/her email address and phone number.
• Insert any special notes that apply to your entity’s practices such as “we never market or sell personal information.”
• The Privacy Rule requires you to describe any state or other laws that require greater limits on disclosures. For example, you might describe the effects of a state law by stating, “We will not share your mental health treatment records without your written consent unless it is for treatment or another law requires us to share the information.” Insert this type of information here. If no laws with greater limits apply to your entity, no information needs to be added.
• If your entity provides patients with access to their health information using an online portal, you may want to insert a reference to it here.
• If your entity is part of an OHCA (organized health care arrangement) that has agreed to a joint notice, use this space to inform your patients of how you share information within the OHCA (such as for treatment, payment, and operations related to the OHCA). Also, describe the other entities covered by this notice and their service locations. For example, “This notice applies to Grace Community Hospitals and Emergency Services Incorporated which operate the emergency services within all Grace hospitals in the greater Dayton area.”

HHS.Gov revised February 16, 2026

Patient Policies, Procedures and Expectations

Patient Code of Conduct

It is our priority to provide a safe and healthy environment for our staff, providers, patients, and accompanying family members. Evergreen Adult Medicine will not tolerate the following behavior:

• Inappropriate language or verbal assault, such as screaming at staff through phone call, voicemail, email or any other messaging system (including digital media).
• Threats of violence of any type.
• Physical assault or threat to cause bodily harm.
• Threats to destroy or physically destroy equipment or property.
• Menacing or derogatory gestures.

Our staff will not engage in such behaviors, and violators will be discharged from the practice immediately. It is our goal to put a stop to such behavior and allow Evergreen Adult Medicine to provide great quality care to the community.

After Hours/On Call Services and Portal Messages

We strongly encourage after hours/on call services to be used for EMERGENT concerns that cannot wait for normal business hours.

Medication refills and prior-authorization messages WILL NOT be handled during non-business hours and are not appropriate for after-hours/on call provider services.

Portal messages should not be used for emergent concerns, as they will not be addressed during non-business hours.

If you choose to reach out to your provider during non-business hours, or anytime via your patient portal, your insurance may be billed as deemed appropriate by provider for utilizing these services. Copays, coinsurance, and deductibles may apply. If the patient is self-pay, the patient may be billed directly.

Patients should never contact our providers directly on their personal home or cell phone, email or social media platforms.

Medication Refills

We understand medication refills, medication shortages, and pharmacy communication have all been very frustrating for patients over the past several years. This is not a simple task to maneuver. As a result, prescription refills may take 2-3 business days to complete a request for medication refills, and 7-10 business days if prior authorization is required by your insurance.

Plan ahead! If you need a refill, please call and leave a detailed message on our nurse line, or request the refill through your patient portal, during normal business hours. Please be aware that refill requests can take up to three (3) business days to complete, therefore it is the patient’s responsibility to plan accordingly. Refill requests will not be handled after hours.

Check your bottle first! Often, patients already have refills on file with the pharmacy. Please call the pharmacy first if refills remain on medication bottle. If there are no refills remaining, please call and leave a detailed message on our nurse line or request a refill via your patient portal. Again, note that refill requests can take up to three (3) business days to complete, and will not be handled after hours.

Prior Authorization

If your medication requires prior authorization, your pharmacist must send our office the rejection notice from your insurance company. This will ensure we have the proper information to complete authorization. Prior authorization can take up to 7-10 business days to complete. We will only do one prior authorization per medication category per calendar year. We will contact the pharmacy with approval. Patients themselves will be notified with medication denials.

Form Fees

There is a form fee for all medical forms including medical leave: $15 for three or less pages, $25 for four pages or more. Please allow 7-10 business days for form completion. Most FMLA and disability paperwork requires extensive documentation, therefore an appointment will also be required. All paperwork must be picked up at our office upon completion. It is the patient’s responsibility to deliver the paperwork to their employer.

Payments

Payment is expected at the time of services rendered. We accept cash, check, Mastercard, Visa, and American Express.

Referrals

An office visit is required for a patient to be referred to a specialist. If insurance requires a referral for any other reason, the patient is responsible to notify Evergreen Adult Medicine regarding the appointment requiring referral. Please allow three to five (3-5) business days for referral completion.

Late Arrivals

We reserve the right to reschedule appointments if a patient arrives more than ten minutes late for a scheduled office visit. This is at the discretion of the scheduled provider. This policy is in place so as not to disrespect the appointment times of other patients. We will do our best to accommodate you based on the provider’s schedule that day. To avoid rescheduling, please plan to arrive 15 minutes prior to your scheduled arrival time.

Cancellation or No Show

Evergreen Adult Medicine requires a 24-hour notice of cancellation prior to any appointment.

Exceptions will be made only on a case-by-case basis for extenuating circumstances.

If you do not give proper notification (24 hours) prior to cancellation, this is considered as a ‘No Show’. Patients will be given a verbal warning after the first ‘No Show’.

A second ‘No Show’ will be accompanied by another verbal notification, in addition to a $50 charge. A third ‘No Show’ in one consecutive year will result in a dismissal from our practice.

A third ‘No Show’ is not guaranteed to be a verbal notification, but rather receipt of a letter in the mail within 3-5 business days with notification of termination. After a third ‘No Show’, a patient will receive thirty (30) days of emergency care by the practice, during which time we advise you to search for active care from another practice.

Frequency of Visits

Most patients are required to see the physician at least every six months for chronic conditions. Frequency of visits are determined by the provider based on multiple factors. Lab work and routine screenings are often required to monitor daily medications for patient safety. Therefore, it is important to comply with routine visits and suggested testing as scheduled. Failure to do so will be considered noncompliance and may result in practice discharge. Sick visits in between chronic care visits do not count as an acceptable visit for medication refills.

Discharge

Evergreen Adult Medicine reserves the right to discharge a patient at any time for noncompliance or inappropriate behavior.

Transfer of Records

Evergreen Adult Medicine requires two weeks’ notice to prepare medical records for transfer. A fee may be charged for this service.

We at Evergreen Adult Medicine consider your healthcare a partnership. We are committed to guiding you to living a happy healthy lifestyle, striving to provide a pleasing personal experience in your health care journey. Thank you for partnering with us on this journey!