NOTICE OF PRIVACY PRACTICES
Operating as Ayafusion Wellness Clinic and Ayafusion Ketamine Clinic
Effective date: 11/01/2026 | Privacy Officer: Richard Clark, APRN, CRNA
2777 Finley Road, Suite 6, Downers Grove, IL 60515 | 773-598-7200 |
admin@ayafusion.com
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.
Our responsibilities
We are required by applicable law to protect the privacy and security of protected health information (PHI), provide this notice of our legal duties and privacy practices, follow the notice currently in effect, and notify affected individuals following a breach of unsecured PHI as required by law. This notice applies to records maintained by Ayafusion Wellness Clinic, PLLC for its clinical services.
How we may use and disclose your information without written authorization
Treatment: We may use and share your information with clinicians and other providers involved in your care. Payment: We may use and disclose information to obtain payment, subject to applicable law and any valid restriction. Healthcare operations: We may use information for quality improvement, staff training, compliance, administration, and other permitted operations. We may contact you about appointments and treatment options. Other disclosures may be permitted or required by law, including public health, health oversight, certain judicial or administrative proceedings, law enforcement in limited circumstances, workers’ compensation, reporting abuse or neglect, and preventing a serious threat to health or safety. Each disclosure is subject to applicable legal conditions and limits.
Family, friends, and people involved in your care
When permitted by law, we may share information relevant to your care or payment with people involved in your care, taking account of your preferences and circumstances. You may tell us not to share with a particular person. Additional protections may apply to certain records and to minors.
Uses and disclosures requiring authorization
We generally require your written authorization for uses or disclosures not otherwise permitted by law, including most uses for marketing, sale of PHI, and most disclosures of psychotherapy notes, if any are maintained. You may revoke an authorization in writing, except to the extent we have already relied on it.
Special protections for mental-health and other sensitive records
Certain health information, including records and communications created in the course of providing mental-health services, may receive additional confidentiality protections under the Illinois Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110) and other applicable laws. When these protections apply, we will obtain the specific written consent required by law before disclosing such information, unless an applicable legal exception permits or requires disclosure. These protections may be more restrictive than the general HIPAA rules for treatment, payment, and healthcare operations.
Your rights
You may request to inspect or obtain a copy of your records, including an electronic copy where applicable; ask us to correct records; request confidential communications by alternative means or locations; request restrictions on uses and disclosures; request an accounting of certain disclosures; obtain a paper copy of this notice; and file a complaint. We must agree to a request not to disclose information to a health plan for payment or operations when you have paid in full out of pocket for the relevant item or service and other legal conditions are met. We may deny certain requests only as allowed by law and will explain
applicable review rights. We will respond to requests within legally required time frames and charge only fees permitted by law.
Complaints and questions
Contact Richard Clark, APRN, CRNA, Privacy Officer, at
admin@ayafusion.com, 773-598-7200, or the mailing address above. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights at
https://www.hhs.gov/ocr/complaints/index.html. We will not retaliate against you for filing a complaint.
Changes to this notice
We may change this notice and make the revised notice effective for PHI we already maintain as permitted by law. The current version will be available at our office, upon request, and on our websites.
