Notice of Privacy Practice ~ Consent for Treatment
As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).This notice describes how health information about you may be used and disclosed and how you can get access to your individually identifiable health information.
Last Diet Ever, is dedicated to maintaining the privacy of your individually identifiable health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.
We may use and disclose your protected health information in the following ways: TREATMENT: We may use your information to treat you. For example, we may ask you to have laboratory tests drawn, and we may use the results to help us reach a diagnosis. We may disclose your information to our pharmacy when we order your prescription for you. Our doctors and staff may use or disclose your information in order to treat you or assist in your care. If given authorization by you, we may disclose your information to other health care providers for purposes related to your treatment. If given authorization by you, we may disclose your information to your spouse, children, parents or other family members who may assist in your care. HEALTH CARE OPERATIONS: We may use and disclose your information to operate our business. DISCLOSURES REQUIRED BY LAW: We will use and disclose your information when we are required to do so by federal, state or local law. SPECIAL CIRCUMSTANCES: We may disclose your information to public health authorities that are authorized by law to collect information for the purpose of: Public Health Risks, Health Oversight Activities, Lawsuits, Law Enforcement, Serious Threats to Health or Safety.
You have the following rights regarding the individually identifiable health information we maintain about you: CONFIDENTIAL COMMUNICATIONS: You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. REQUESTING RESTRICTIONS: You have the right to request a restriction in our use or disclosure of your information. Your request must be made in writing. We are not required to agree to your request, however, if we do agree, we are bound by our agreement except when required by law, in emergencies or when the information is necessary to treat you. INSPECTION OF COPIES: You have the right to inspect and obtain a copy of your information that we have on file. We may charge a fee for the costs of copying and mailing associated with your request, which must be in writing. AMENDMENT: You may ask us to amend your health information if you believe it is incorrect or incomplete. This must be made in writing. RIGHT TO A PAPER COPY OF THIS NOTICE: You are entitled to receive a paper copy of our Notice of Privacy Practices (upon request).
By signing below, I agree to the following: I give permission to leave a PHONE MESSAGE with another person, or on an answering machine, and/or voicemail at my home or cellular phone. I give permission to send an E-MAIL: I give permission to MAIL correspondence to my home address.