HIPAA Privacy Policy

NOTICE OF PRIVACY PRACTICES

Specialty Dripps by Afton

This Notice of Privacy Practices (“Notice”) describes how health information about you (as a client of Specialty Dripps by Afton, hereinafter referred to as “DRIPPS”) may be used and disclosed and how you can get access to your Individually Identifiable or Personal Health Information (PHI). This information is required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

PLEASE REVIEW THE FOLLOWING NOTICE CAREFULLY

Our Commitment to your privacy:

DRIPPS 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 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 concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

DRIPPS must provide you with the following important information:

How we may use and disclose your PHI
Your privacy rights in your PHI
Our obligations concerning the use and disclosure of your PHI

We may use and disclose your PHI in the following ways:

Treatment: DRIPPS may use your PHI to treat you by providing, coordinating, or managing services by one or more providers.
Operations: DRIPPS may use your PHI to operate our business, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, obtaining payment, and customer service.
Appointment Reminders: DRIPPS may use and disclose your PHI to contact you and remind you of an appointment.
Electronic Transmission: DRIPPS may display the office name, address, and patient identifiable information on electronic transmissions.
Release of Information to Family/Friends: DRIPPS may release your PHI to a friend or family member authorized by you.

Use and disclosure of your PHI in certain special circumstances:

For public health activities including reporting of certain communicable diseases.
To authorities when we suspect abuse, neglect, or domestic violence.
To health oversight agencies.
For judicial and administrative proceedings pursuant to an administrative order.
For law enforcement purposes.
To avert a serious threat to your health and safety or that of others.
For governmental purposes such as military service or for national security.
In the event of an emergency or for disaster relief.
For Worker’s Compensation or similar programs as required by law.
Inclusive of any other instance required by law.

Your rights regarding your PHI:

Confidential communications: You have the right to request that DRIPPS communicate with you in a particular manner or at a certain location.
Requesting Restrictions: You have the right to request a restriction in our use of disclosure of your PHI treatment, payment, or operations.
Inspection of Copies: You have the right to inspect and obtain copy of the PHI that may be used to make decisions about you, including services records and billing records.
Amendment: You may ask us to amend your information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for DRIPPS. To request an amendment, your request must be made in writing providing a reason that supports your request.
Accounting of Disclosures: All patients have the right to request an “accounting of disclosures” consisting of a list of certain non-routine disclosures DRIPPS has made of your PHI for purposes not related to treatment, payment or operations.
Right to a Paper Copy of this Notice: You are entitled to receive a paper copy of our notice of privacy practices.
Right to File a Complaint: If you believe your privacy rights have been violated, you may file a written complaint with our office, or with the Department of Health and Human Services, or the Office of Civil Rights.
Right to Provide an Authorization for Other Uses and Disclosures: DRIPPS will obtain written authorization for uses and disclosures that are identified by this notice or permitted by applicable law.
Right to Revoke: You may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the revocation date will not be affected.

DRIPPS is required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change terms of our Notice of Privacy practices and to make the new provisions effective for all protected health information that we maintain.

For more information about HIPAA or if you have any questions about this Notice, please contact: Specialty Dripps by Afton

6698 S. Iris St Unit #621001, Littleton, CO 80123, Phone: 720-593-1846

Receipt of Notice of Privacy Practices Written Acknowledgement Form

I agree I have reviewed a copy of DRIPPS Notice of Privacy Practices.

Signature of Client on file with EMR

Authorization to Release Information

Please provide us with the names of any person or persons we are allowed to share your PHI, otherwise we MAY NOT do so even with a spouse or relative without this authorization.

I hereby authorize (name) _________________ (relation) _____________________ (phone) _____________ to receive any information concerning me from DRIPPS.

Client’s Signature Date Client’s Printed Name