Notice of Privacy Practices
The Unencumbered Appetite LLC, www.theunencumberedappetite.com
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOWYOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed toprotecting health information about you. I create a record of the care and services you receive from me.I need this record to provide you with quality care and to comply with certain legal requirements. Thisnotice applies to all of the records of your care generated by this practice. This notice will tell you aboutthe ways in which I may use and disclose health information about you. I also describe your rights to thehealth information I keep about you, and describe certain obligations I have regarding the use anddisclosure of your health information. I am required by law to:
Make sure that protected health information (“PHI”) that identifies you is kept private.
Give you this notice of my legal duties and privacy practices with respect to health information.
Follow the terms of the notice that is currently in effect.
I can change the terms of this Notice, and such changes will apply to all information I have aboutyou. The new Notice will be available upon request, in my office, and on my website.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For eachcategory of uses or disclosures I will explain what I mean and try to give some examples. Not every useor disclosure in a category will be listed. However, all of the ways I am permitted to use and discloseinformation will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health careproviders who have direct treatment relationship with the patient/client to use or disclose thepatient/client’s personal health information without the patient’s written authorization, to carry out thehealth care provider’s own treatment, payment or health care operations. I may also disclose yourprotected health information for the treatment activities of any health care provider. This too can bedone without your written authorization. For example, if a health care provider were to consult withanother licensed health care provider about your condition, we would be permitted to use and discloseyour personal health information, which is otherwise confidential, in order to assist the health careprovider in diagnosis and treatment of your condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
Session Notes: I do keep “Session notes” and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising associates to help them improve their clinical skills.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the session notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. As a health care provider, I will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a health care provider, I will not sell your PHI in the regular course of my business.
. .
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
. .
For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners, when such individuals are performing duties authorized by law.
For research purposes, including studying and comparing the patients who received one form of care versus those who received another form of care for the same condition.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers’compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’compensation laws.
Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
. . .
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
. . .
The Right to See and Get Copies of Your PHI. Other than “session notes,” you have the right to getan electronic or paper copy of your medical record and other information that I have about you. Iwill provide you with a copy of your record, or a summary of it, if you agree to receive a summary,within 30 days of receiving your written request, and I may charge a reasonable, cost based fee fordoing so.
The Right to Get a List of the Disclosures I Have Made.You have the right to request a list ofinstances in which I have disclosed your PHI for purposes other than treatment, payment, or healthcare operations, or for which you provided me with an Authorization. I will respond to your requestfor an accounting of disclosures within 60 days of receiving your request. The list I will give you willinclude disclosures made in the last six years unless you request a shorter time. I will provide thelist to you at no charge, but if you make more than one request in the same year, I will charge you areasonable cost based fee for each additional request.
The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that apiece of important information is missing from your PHI, you have the right to request that I correctthe existing information or add the missing information. I may say “no” to your request, but I will tellyou why in writing within 60 days of receiving your request.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy ofthis Notice, and you have the right to get a copy of this notice by e-mail. And, even if you haveagreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
. . .
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on Aug, 19, 2024.
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rightsregarding the use and disclosure of your protected health information.
Practice Policies
The Unencumbered Appetite LLC, www.theunencumberedappetite.com
PRACTICE POLICIES
APPOINTMENTS AND CANCELLATIONSPlease remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire feeif cancellation is less than 24 hours.
The standard meeting time for a Nutrition Follow-Up Session is 50 minutes. It is up to you, however, todetermine the length of time of your sessions. Requests to change the 50 minute session needs to bediscussed with the health care provider in order for time to be scheduled in advance.
A $25 service charge will be charged for any checks returned for any reason for special handling.
Cancellations and re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 24HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is heldexclusively for you. If you are late for a session, you may lose some of that session time.
TELEPHONE ACCESSIBILITYIf you need to contact me between sessions, please leave a message on my voicemail. I am often notimmediately available; however, I will attempt to return your call within 24 hours. Please note that Face-to-face sessions are highly preferable to phone sessions. However, in the event that you are out oftown, sick or need additional support, phone sessions are available. If a true emergency situation arises,please call 911 or any local emergency room.
SOCIAL MEDIA AND TELECOMMUNICATIONDue to the importance of your confidentiality and the importance of minimizing dual relationships, I donot accept friend or contact requests from current or former clients on any social networking site(Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites cancompromise your confidentiality and our respective privacy. It may also blur the boundaries of ourtherapeutic relationship. If you have questions about this, please bring them up when we meet and wecan talk more about it.
ELECTRONIC COMMUNICATION I cannot ensure the confidentiality of any form of communicationthrough electronic media, including text messages. If you prefer to communicate via email or textmessaging for issues regarding scheduling or cancellations, I will do so. While I may try to returnmessages in a timely manner, I cannot guarantee immediate response and request that you do not usethese methods of communication to discuss therapeutic content and/or request assistance foremergencies. Services by electronic means, including but not limited to telephone communication, theInternet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under theCalifornia Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and yourpractitioner chose to use information technology for some or all of your treatment, you need tounderstand that:
You retain the option to withhold or withdraw consent at any time without affecting the right tofuture care or treatment or risking the loss or withdrawal of any program benefits to which youwould otherwise be entitled.
All existing confidentiality protections are equally applicable.
Your access to all medical information transmitted during a telemedicine consultation isguaranteed, and copies of this information are available for a reasonable fee.
Dissemination of any of your identifiable images or information from the telemedicine interaction toresearchers or other entities shall not occur without your consent.
There are potential risks, consequences, and benefits of telemedicine. Potential benefits include,but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditionsof practice, improved access to treatment, better continuity of care, and reduction of lost work timeand travel costs. Effective treatment is often facilitated when the healthcare provider gathers withina session or a series of sessions, a multitude of observations, information, and experiences aboutthe client. The provider may make assessments, diagnosis, and interventions based not only ondirect verbal or auditory communications, written reports, and third person consultations, but alsofrom direct visual and olfactory observations, information, and experiences. When usinginformation technology in services, potential risks include, but are not limited to the provider’sinability to make visual and olfactory observations of clinically or therapeutically potentially relevantissues such as: your physical condition including deformities, apparent height and weight, bodytype, attractiveness relative to social and cultural norms or standards, gait and motor coordination,posture, work speed, any noteworthy mannerism or gestures, physical or medical conditionsincluding bruises or injuries, basic grooming and hygiene including appropriateness of dress, eyecontact (including any changes in the previously listed issues), sex, chronological and apparentage, ethnicity, facial and body language, and congruence of language and facial or bodilyexpression. Potential consequences thus include the provider not being aware of what they wouldconsider important information, that you may not recognize as significant to present verbally to theprovider.
. . .
MINORS If you are a minor, your parents may be legally entitled to some information about your treatment. I willdiscuss with you and your parents what information is appropriate for them to receive and which issuesare more appropriately kept confidential.
TERMINATION Ending relationships can be difficult. Therefore, it is important to have a terminationprocess in order to achieve some closure. The appropriate length of the termination depends on thelength and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the treatment is not being effectively used or if you are indefault on payment. I will not terminate the therapeutic relationship without first discussing andexploring the reasons and purpose of terminating. If treatment is terminated for any reason or yourequest another provider, I will provide you with a list of qualified Dietitians to treat you. You may alsochoose someone on your own or from another referral source. Should you fail to schedule anappointment for three consecutive weeks, unless other arrangements have been made in advance, forlegal and ethical reasons, I must consider the professional relationship discontinued.