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HIPPA and Consent for Treatment

HIPPA Information

NOTICE OF PRIVACY PRACTICES

 

We understand the importance of privacy and are committed to maintaining the confidentiality of your personal information. We are required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices with respect to protected health information. This notice also describes your rights and legal obligations to your personal information.

 

A.  HOW THIS PRACTICE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION

This clinic collects health information about you and stores it on a computer. This is your personal record. This personal record is the property of this clinic, but the information in the personal record belongs to you. The law permits me to use or disclose your health information only for the following purposes:

 

  1. TREATMENT:  We use personal information about you to provide your care. We disclose personal information to our employees and others who are involved in providing the care you need. For example, we may share your personal information with other health care providers who may provide services that we do not provide.

  2. PAYMENT:  We use and disclose personal information about you to obtain payment for the services we provide.

  3. HEALTH CARE OPERATIONS:  We may use and disclose personal information about you to operate this clinic. For example, we may share your personal information with our “business associates,” such as my online scheduling service, that perform administrative services for me. We have a written contract with associates that contains terms requiring them to protect the confidentiality of your personal information.

  4. NOTIFICATION AND COMMUNICATION WITH FAMILY:  We may disclose your health information to a family member, your personal representative or another person responsible for your care. If you are able and available to agree or object we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, your health professionals will use their best judgment in communication with your family and others.

  5. REQUIRED BY LAW:  As required by law, we will use and disclose your health information, but we will limit my use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence or respond to judicial or administrative proceedings or to law enforcement officials we will further comply with the requirement set forth concerning those activities.

  6. WORKERS’ COMPENSATION:  We may disclose your health information as necessary to comply with workers’ compensation laws. For example, to the extent that your care is covered by workers’ compensation, we will make periodic reports to the workers’ compensation insurer about your condition.

  7. CHANGES OF OWNERSHIP:  In the event that this clinic is sold or merged with another organization, your health information/records will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.

B.   WHEN THIS CLINIC MAY NOT USE OR DISCLOSE YOUR HEALTH INFORMATION

 

Except as described in this Notification of Privacy Practices, this clinic will not use or disclose health information that identifies you without your written authorization. If you do authorize this clinic to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

 

C.   YOUR HEALTH INFORMATION RIGHTS

 

  1. RIGHT TO REQUEST SPECIAL PRIVACY PROTECTION:  You have the right to request restrictions on certain uses and disclosures of your health information by a written request specifying what limitations to disclosures you are requesting.

  2. RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS:  You have the right to request that you receive your health information in a specific way or location, such as at your work address or phone number. We will comply with all reasonable requests submitted in writing that specify how you wish to receive your health information.

  3. RIGHT TO INSPECT AND COPY:  You have the right to inspect and receive a copy (or copies) of your personal information. To access your personal information, submit a written request detailing what you want to see or have copied. A reasonable fee may be charged to copy a chart.

  4. RIGHT TO AMEND OR SUPPLEMENT:  You have the right to request that we amend your health information that you believe is incorrect or incomplete. We are not required to change your health information and will provide you with information about a denial or how you can disagree with a denial. We may deny your request if we do not have the information or if we did not create the information. You also have the right to request that we add to your record a statement of up to 250 words concerning any statement or item that you believe to be incorrect or incomplete.

  5. RIGHT TO AN ACCOUNTING OF DISCLOSURES:  You have a right to receive an accounting of disclosures of your health information made by this clinic, except that this practice does not have to account for the disclosures provided to you pursuant to your written authorization or as directed in paragraphs 1-7 above.

YOU HAVE A RIGHT TO A PAPER COPY OF THIS NOTICE OF PRIVACY PRACTICES

Consent for Treatment

I understand that I am going to receive treatment from a practitioner working for Healing for People Inc., and hereby consent to this treatment. I understand that they are licensed under the Massage Board of Florida and are not engaged in the practice of medicine, psychiatry, psychology, or any other licensed profession.

 

I have been duly informed of the nature, risks, and possible complications or consequences of energy healing treatments. I agree to inform my practitioner about any special needs which I have pertinent to my mental or physical health, and to discuss my goals in receiving this treatment based upon my unique life experiences.

 

I am undergoing this treatment voluntarily of my own free will, and I understand that I may stop or limit this treatment at any time without explanation. I know that the practice of energy healing is not an exact science, and I have neither asked for nor received any guarantees or promises as to the results which will be obtained. I also understand that Healing for People, Inc., reserves the right to refuse to provide treatment to anyone.

 

I understand that my right to privacy and confidentiality will be respected by the practitioner. The privacy policy and practices of Healing for People, Inc., have been explained to me, and I have received written notice of them, as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

 

I understand that there may be certain risks arising out of my voluntary participation in receiving energy healing treatments. As consideration for being permitted to participate in the art of energy healing, I accept and assume complete responsibility for all such risks and, to the maximum extent permitted by public policy and the law, I hereby voluntarily waive any and all claims I may have, now or in the future, against Healing for People, In.c, or any of its practitioners, directors, officers, volunteers, students, employees, agents, independent contractors or representatives (hereafter referred to as “the Released Parties”), for any and all personal injury, emotional injury, sickness, disease, death, property damage, economic damage or any other loss arising out of or in connection with my receipt of energy healing treatments, or my presence in or about the office or other facilities occupied by the Released Parties, even if the injury, damage or loss was caused by or aggravated by the negligence, carelessness or other act or failure to act of any of the Released Parties.

 

To the maximum extent permitted by public policy and the law, I hereby release the Released Parties from and against all demands, claims, actions, damages, costs and expenses, with respect to any personal injury, emotional injury, sickness, disease, death, property damage, economic damage or any other loss arising out of or in connection with my receipt of energy healing treatments, or my presence in or about the office or other facilities occupied by the Released Parties, whether such claim arises by contract, by tort, in equity, or by reason of breach of a legal or statutory duty.

 

I HAVE CAREFULLY READ THIS CONSENT TO TREATMENT, ASSUMPTION OF RISK, WAIVER AND RELEASE AND I FULLY UNDERSTAND EACH OF ITS TERMS. I SIGN THIS AGREEMENT KNOWINGLY AND VOLUNTARILY, AND AGREE TO BE BOUND BY IT.

 

FOR CALIFORNIA RESIDENTS ONLY:

I acknowledge that I have been made aware of the provisions of Section 1542 of the California Civil Code, which states:

 

A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE

CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM MUST HAVE MATERIALLY AFFECTED HIS SETTLEMENT WITH THE DEBTOR.

As further consideration for being permitted to participate in the art of energy healing, I hereby voluntarily waive any and all rights I may have under Section 1542 of the California Civil Code with respect to the demands, claims, actions, damages, costs and expenses described herein. In the event that any part of this Agreement is held to be invalid or unenforceable by a court of competent jurisdiction, the invalid or unenforceable part shall be severed from this Agreement and remaining parts shall continue to be valid and enforceable as though the invalid or unenforceable parts had not been included herein. I acknowledge and agree that no modification or amendment of this Agreement shall be effective, unless the modification or amendment is in a writing signed by both myself and an authorized representative of Healing for People, Inc. The construction and interpretation of this Agreement shall be governed by the laws of the State of Florida.

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