If you have any questions, please contact:
Cindy Lindsey
Totally Fit 4 Life
7476 Waterside Loop Rd. Suite 600
Denver, NC 28037
(704) 822-5433
OUR PLEDGE REGARDING MEDICAL INFORMATION
Totally Fit 4 Life is committed to protecting your privacy. We understand that information you share with us is personal. Our medical records are created to provide you with the utmost in care and meet certain legal requirements that we must comply with. This notice covers all information concerning you and your care. This notice will explain the ways we may use and disclose your information, and your rights concerning your information. We will also explain certain obligations we have regarding the use and disclosure of medical information. No other use or disclosure than those described in this privacy notice can be made without your written and non-revoked authorization.
We are required to make sure medical information that identifies you is kept private. We must give you this notice of our legal duties and privacy practices with respect to medical information about you. We are required by law to follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe how we use and disclose medical information.
FOR TREATMENT
We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to personnel within Totally Fit 4 Life who are responsible for your care. For example, your protected health information may be sent to your primary physician in order to assist him/her with your treatment.
FOR PAYMENT
We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party.
HEALTHCARE OPERATIONS: We may use of disclose, as needed, your protected health information in order to support the business activities of Totally Fit 4 Life. These activities include, but are not limited to, quality assessment activities, employee review activities, training, and conducting or arranging for other business activities. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate what service you at the office for. We may also call you by name in the waiting room when your counselor is ready to see you. We may also use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: As required by law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration Requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donation, Research, Criminal Activity, Military Activity and National Security, Workers’ Compensation, Inmates, Required Uses and Disclosures under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with HIPAA requirements.
OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES Will be made only with your authorization or Opportunity to object unless required by law. You may revoke this authorization at any time, in writing, except to the extent that Totally Fit 4 Life has taken an action in reliance on the use or disclosure indicated in the authorization.
YOUR RIGHTS
Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom and what the restrictions apply.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us at anytime.
You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
COMPLAINTS
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.
This notice was published and becomes effective on/or before September 14, 2007.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices in respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.
TOTALLY FIT 4 LIFE™1920 East Marion Street 1126 Lenoir-Rhyne Blvd. SE Shelby, NC 28152 Hickory, NC 28602
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I hereby acknowledge that I received the Totally Fit 4 Life’s Notice of Privacy Practices.
_______________________________________ _________________ Signature of Patient or Patient Representative Date
DOCUMENTATION OF GOOD FAITH EFFORTS TO OBTAIN PATIENT’S ACKNOWLEDGEMENT THAT THEY RECEIVED PROVIDER’S NOTICE OF PRIVACY PRACTICES
(For use when acknowledgement that they received provider’s Notice of Privacy Practices)
The patient presented to the office on ______________(date) and was provided with a copy of Totally Fit 4 Life’s Notice of Privacy Practices. A good faith effort was made to obtain from the patient a written acknowledgement of his/her receipt of the Notice. However, such acknowledgement was not obtained because:
_____ Patient refused to sign.
_____Patient was unable to sign or initial because: ___________________________________________________________________________ ___________________________________________________________________________
________________________________________________ ____________________ Signature of Employee Completing Form Date
9/14/2007
