Notice of Health Information Privacy Practice

The Department of Health and Human Services has established a "Privacy Rule" to help insure that personal care information is protected for privacy. Federal legislation concerning patient privacy requires health care providers, health insurance companies and other health related organizations to bolster their privacy practices as of April 14, 2003. At Wellness Iv Infusions we consider the privacy of your health information to be one of the most important elements in our relationship with you. We are pleased to provide this information to our patients and to comply with the privacy regulations of the federal Health Insurance Portability and Accountability Act (HIPPA). To help us comply with this law, we ask that you read carefully and sign this notice acknowledging you have read it and understand it. As our patient/customer, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest. We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories, attorneys, collection agencies, law enforcement officials, worker's compensation, etc.), and may have to disclose personal health information for the purpose of treatment, payment, or healthcare operations. These entities are most often not required to obtain patient consent. You, as the patient, have the right to receive one free copy of your medical records. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing under this law. We have the right to refuse to treat you should you choose to refuse to disclose your Personal Health information (PHl). lf you choose to give consent in this document, at some future time you may request to refuse all or part of your PHl. You revoke actions that have already been taken which relied on this or a previously signed consent. Additionally you consent our staff to contact your doctor for the release of medical records. lf you have any objections to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice, to request restriction, and to revoke consent in writing after you have reviewed our privacy notice.