I understand that Ambition HomeCare LLC is required by law to maintain the privacy and security of my protected health information (PHl).

I give permission for Ambition HomeCare LLC staff to use and disclose my health information as necessary to coordinate and provide non-medical care services, including communication with healthcare providers, emergency personnel, or authorized family members.

I understand that any information will only be shared when it is directly related to the services I receive, or when required by law.

I have been informed that I may request a copy of the agency's full Privacy Notice, which provides detailed information about how my health data is handled, stored, and protected.

I may revoke this consent at any time in writing, except where action has already been taken in reliance on it.

I understand that I may request access to review or obtain copies of my health and service records, and I have the right to request corrections if I believe the information is inaccurate.

Ambition HomeCare LLC will never sell or distribute my personal information for marketing purposes or non-care-related uses.

All staff members are trained on HIPAA privacy practices and are subject to disciplinary action for any violations.

I understand that my information may be used for internalquality improvement, agency compliance monitoring, or legal documentation as necessary.

I understand that I may file a complaint with Ambition HomeCare LLC or the U.S. Department of Health & Human Services if I feel my HIPAA rights have been violated.

I acknowledge that it is my responsibility to notify Ambition HomeCare LLC of any changes in my emergency contact, authorized representative, or any restrictions I wish to place on the release of my information.

I consent to the secure storage of my intake, service, and care records in paper or electronic form by Ambition HomeCare LLC in compliance with federal and state regulations.

I understand that certain information may be stored or processed by third-party vendors (e.g., scheduling software or secure file storage platforms) under strict confidentiality agreements.

I understand that my care-related communication may occur via phone, text, email, or secure electronic platforms. I accept the risks associated with electronic communication unless I request otherwise in writing.

I understand that Ambition HomeCare LLC will make reasonable efforts to use, disclose, or request only the minimum necessary amount of personal information to accomplish the intended purpose.

I acknowledge that my service and health-related records wilt be retained by the agency for a minimum period required by Maryland law, even after termination of services.

I understand that Ambition Homecare LLC may be legally required to disclose my information in response to court orders, legal investigations, audits, or public health reporting obligations.

I do / do not give permission for Ambition HomeCare LLC to take and store photos or audio recordings for the purpose of care documentation or quality assurance.

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.