HIPAA NOTICE

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.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required to provide this notice to you by the Health Insurance Portability and Accountability Act (“HIPAA”).

 1. Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your provider, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate or manage your health care and

any related services. This includes the coordination or management of your health care with a third party. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. Healthcare Operations: We may use or disclose, as needed, your health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. We will share your protected health information with third-party “business associates” who perform various activities (for example, Billing, transcription services) for any health plan. The business associates will also be required to protect your health information.

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, and Organ Donation: Research: Criminal Activity: Military Activity an 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 the requirements of Section164.500.

 2. Other Permitted and Required Uses and Disclosures Will be Made Only with Your Consent, Authorization or Opportunity to Object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your provider or the provider’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

 3. 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 on 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 purpose 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 of for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your provider is not required to agree to a restriction that you may request. If provider believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You have the right to have your provider 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 Service 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 is effective in its entirety as of June 6th, 2022.

 4. CONTACT INFORMATION We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with 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 (865) 286-9229.Signature below is only acknowledgement that you have received this Notice of our Privacy Practices.

give my express written permission to Care in Faith Family Wellness, to obtain access and disclose all of my medical records. I understand that my personal and medical information may be stored on a password protected secure cloud service.

FINANCIAL AND PAYMENT GUIDELINES

Notice: Our office does NOT file Insurance claims for office visits.

I understand that I am financially responsible for all charges for services rendered by Care in Faith Family Wellness. All charges are due and time of service. I understand I will be financially responsible for any charges due to claims rejected or denied by my healthcare insurance carrier. I understand that in the event I do not cancel my appointment within twenty-four hours of the scheduled appointment that the clinic may charge a cancellation fee.

 

 CONSENT FOR TREATMENT, RELEASE OF INFORMATION, & AUTHORIZATION

 I consent to treatment necessary to the care which has been discussed and directed by the provider. I request and give consent to Care in Faith Family Wellness to provide and perform such medical care, tests, medication, and other services and supplies as are considered necessary or beneficial by my provider for my health and well-being. I acknowledge that no representations, warranties or guarantees as to the result or cures have been made to me or relied upon by me.

 I authorize the release of all medical records to specialists and/or consulting physicians if applicable to my care and condition.