Rejuvenations Inc / Dr. Repice
NOTICE OF PRIVACY PRACTICES
HIPAA Privacy Authorization Form **Authorization for Use or Discolsure or Protected Health Information (Required by the Health Insurance Portability & Accountability Act, 45 C.F.R. Parts 160 and 164)**
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Uses and disclosures- Please read this in its entirety and carefully.
Treatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory test and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
Payment: Payment is collected prior or at the time the Consultation / Coaching Call is initiated . We accept all major Credit Cards
Health care operations: Your health information may be used as necessary to support the day-to-day activities and management of this practice; REJUVENATIONS INC & DR REPICE. For example, information on the service you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
Law enforcement: Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits an inspections to facilitate law enforcement investigations and to comply with government mandated reporting.
Public health reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s health department.
Other uses and disclosures: Disclosure of you health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use of disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use of disclosure of information that occurred before you notified us of your decision.
Additional uses of information:
Appointment reminders: Your health information will be used by our staff to send you appointment reminders.
Information about treatments: Your health information may be used to send your information on the treatment and management of your medical condition that you may find to be of interest. We may also send your information describing other health-related goods and service that we believe may interest or be of benefit to you.
Individual Rights: You have certain rights under the federal privacy standards. These include:
* The right to request restrictions on the use and disclosure of your protected health information.
* The right to receive confidential communication concerning your medical conditions and treatment.
* The right to inspect and copy your protected health information.
* The right to amend or submit corrections of your protected health information.
* The right to receive an accounting of how and to whom your protected health information has been disclosed.
* The right to receive a printed copy of this notice.
The duties of this medical practice known as REJUVENATIONS INC / DR REPICE. We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices.
We are also required to abide by the privacy policies and practices that are outlined in this notice. As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state law and regulation. Whatever the reason for the revision, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.
Request to inspect information: As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access by asking our receptionist or contacting the Privacy Officer in writing.
Complaints: If you would like to submit a comment or complaint about our privacy practices, or suspect violation, you do so by letter, outlining your concerns. Please address this correspondence to The Privacy Officer care of this medical practice at our current address.