Yancy Camp Nutrition Intake Form & Privacy Policy

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present, and future physical and mental health condition and related health care services are referred to as Protected Health Information (PHI). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon request or providing one to you at your next appointment.

For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization. For Payment: We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection. For Health Care Operations: We may use or disclose, as needed, your PHI in order to support out business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For examples, we may share your PHI with third parties that perform various business activities (ie: billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training and teaching purposes, PHI will be disclosed only with your authorization. Required by Law: Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating and determining our compliance with the requirement of the Privacy Rule. Without Authorization: Applicable law and ethical standards permit us to disclose information about you without our authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are: Required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations such as the counseling licensing board or the health department. Required by court order. Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person(s) reasonably able to prevent or lessen the threat, including the target of the threat. Verbal Permission: We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission. With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to Amy Culp, PO Box ___, _______, TX XXXXX-XXXX. Right of Access to Inspect and Copy. You have the right to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where compelling evidence that access would cause serious harm to you. Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. Right to an Accounting of Disclosures. You have the right to request an accounting of certain disclosures that we make of your PHI. Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request. Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Right to a Copy of this Notice. You have the right to a copy of this notice.