Take Time For You
Notice of Privacy Practices
Effective Date: 04/11/2016
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.
We understand that medical information about you is personal and we are committed to protecting it. Simply Be Massage is required by law to maintain the privacy of your health information, to follow the terms of this notice, and to provide you with this notice of our legal duties and privacy practices with respect to your health information. We are required to follow the terms of the notice that is currently in effect.
How Simply Be Massage may use or disclose your health information:
For treatment – to dispense and provide services to you.
For payment – so that your massage services may be billed and payment be collected from you, your insurance or a third party.
For health Care Operations – massage services, which include activities necessary to run my business and make sure that you receive quality customer service.
For appointment reminders and health related products and services – we may use and disclose health information for massages, to tell you about health-related products and services or recommend possible treatment alternatives that may be of interest to you.
To individuals involved in your care or payment for your care – we may disclose your health information to a family member or friend who is involved in your medical care or payment for your care, provided that you agree to the disclosure, or we give you an opportunity to object to the disclosure. If you are not available or are unable to agree or object, we will use our best judgment to decide whether this disclosure is in your best interest.
As required by law – to comply with federal, state or local law.
To avert a serious threat to health or safety – we must use and disclose your health information when necessary to prevent a serious threat to your health and safety of the health and safety of the public or another person. Any disclosure would be only to someone able to avert the threat.
For public health activities/risk prevention – for public health activities including for example, activities to prevent or control disease of injury; report problems with products; or, report abuse or neglect.
For health oversight activities – to a health oversight agency for activities authorized by law. These activities, which are necessary for the government to monitor the health care system, include audits, investigations, inspections and licensure.
For lawsuits and dispute – if you are involved in a lawsuit or dispute, we may disclose your health information in response to a court or administrative order. 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 (which may include written notice to you) or to obtain an order protecting that information.
For specialized government functions – (1) if you are a member of the armed forces, as required by military command authorities; (2) if you are an inmate or in lawful custody to a correctional facility or law enforcement official; (3) in response to a request from law enforcement, if certain conditions are satisfied; (4) for national security reasons authorized by law; and (5) to authorized federal officials to protect the President, other authorized persons of head of state.
For worker’s compensation or other similar programs.
Organ and tissue donation – to organ procurement or similar organizations for purposes of donation or transplant.
Coroners or funeral directors – to a coroner or medical examiner, for example, to determine cause of death. To funeral directors consistent with applicable law to enable them to carry out their duties.
Personal representative – to a person legally authorized to act on your behalf, such as a parent, legal guardian, administrator or executor of your estate, or other individual authorized under applicable law.
Marketing – with your written authorization, we may use your health information or disclose your health information to our third party agents, representatives, service providers and/or contractors to offer targeting marketing communications to you.
You have the following rights with respect to your health information.
You have the right to request that we follow special restrictions when using or disclosing your health information for treatment, payment or health care operations, or to someone who is involved in your care or the payment of your care. Simply Be Massage in not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment and other exceptions pursuant to law.
With certain exceptions, you have the right to inspect and copy your health information. Usually, such information includes billing records. We may deny your request to inspect and copy in certain limited circumstances, in which case, you may request that the denial be reviewed.
You have the right to request that Simply Be Massage amend your health information if you feel that it is incorrect or incomplete. You must provide a reason supporting your request. We may deny your request if the health information is accurate and complete or is not part of the health information kept by or for Simply Be Massage. Even if we deny your request of the amendment, you have the right to submit a statement of disagreement regarding any item in your record you believe is incomplete or incorrect. If you request, this will become part of your medical record, and we will attach it to your records and include it whenever we make a disclosure of the item or statement you believe is incomplete or incorrect.
You have the right to request an accounting of disclosures of your health information. This is a list of disclosures we made of your health information, other than for treatment, payment, health care operations, and other exceptions pursuant to law. You must specify the time period, which may not be longer than six years and may not include dates before September 01, 2015.
You have the right to request that we communicate with you about medical matters in a certain way or at a certain locations. For example, you may have a request that we contact you only at work or at a different residence or post office box. We will accommodate all reasonable requests.
Changes to this Notice of Privacy Practices
Simply Be Massage reserves the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in our handbook. If we change our Notice, you may obtain a copy of the revised version upon request. By signing below, I acknowledge that I have read the above Notice of Privacy Practices.
______________________________________ Signature of Client or Authorized Representative Date ___________________________