Privacy Policies
Consent to Treatment
I have read through all the above information and have been clearly advised of my rights and responsibilities as a client of Faiths Nutrition Counseling LLC.
I understand these rights and responsibilities and agree to abide by them. I consent to treatment, and I understand I have a right to receive a copy of this form upon request. I also understand that I can withdraw this consent in writing and terminate at any time.
Financial Policy Agreement
Please review and acknowledge the following financial policies for Faiths Nutrition Counseling LLC. This agreement helps ensure clear communication regarding payment expectations and responsibilities.
1. Payment Responsibility
● Insurance and Out-of-Pocket Payments: I understand that I am responsible for all fees not covered by my insurance, including deductibles, copays, and coinsurance.
● Payment at Time of Service: I agree to pay any self-pay fees at the time of my appointment.
● Card on File Requirement: I agree to keep a credit card on file for use in processing unpaid balances, missed appointment fees, and cancellation fees.
2. Cancellation and No-Show Policy
● Cancellation Notice: I agree to provide at least 24 hours’ notice for any cancellations or rescheduling.
● I understand the card on file will be charged for any missed appointments or cancellations made without sufficient notice and will incur a fee of:
○ Late Cancellation Fee (within 24 hours’ notice): $15.00
○ No-Show Fee: $30.00
3. Insurance and Billing Policies
● Insurance Verification: I acknowledge that my insurance benefits will be verified as a courtesy, but verification does not guarantee payment, and I am responsible for any balances remaining after insurance.
● Claim Reprocessing: Our billing team will reprocess any denied claims as necessary, but I understand that I am responsible for unpaid amounts after reprocessing.
● Explanation of Benefits (EOB): I will receive an EOB from my insurance provider detailing the status of each claim.
● In the event that an insurance company rescinds, retracts, or otherwise reverses payment for services previously rendered - commonly referred to as a “clawback” - I (the client) acknowledges and agrees to assume full financial responsibility for the recouped amount. Such reversals may result from but are not limited to post-payment audits, eligibility changes, or policy terminations. The client agrees to remit full payment of any outstanding balance within thirty (30) days of notification.
4. Additional Fees
● Session Rate Changes: I understand that session rates may change, and advance notice will be provided.
5. Collections Policy
● Unpaid Balances: I understand that unpaid balances may be subject to collections procedures if not paid within a specified period. Payment plans may be available upon request for larger balances.
HIPAA Notice of Privacy Practices
This notice describes how protected health information about you may be used and disclosed and how you can get access to this information. Please review this carefully.
Our Pledge Regarding Protected Health Information
We understand that protected health information about you and your health is personal. We are committed to
protecting health information about you. This Notice applies to all records of your care generated by us.
This Notice will tell you about the ways in which we may use or disclose protected health information about
you. We also describe your rights and certain obligations we have regarding the use and disclosure of
protected health information. Federal law requires us to:
- Make sure that protected health information that identifies you is kept private;
- Notify you about how we protect protected health information about you;
- Explain how, when, and why we use and disclose protected health information; and - Follow the terms of the
Notice that is currently in effect.
We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new Notice provisions effective for all protected health information that we maintain by:
- Posting the revised Notice in our office;
- Making copies of the revised Notice available upon request; and - Posting the revised Notice on our Website.
How We May Use and Disclose Protected Health Information About You
The following categories describe different ways that we may use and disclose protected health information
without your written authorization.
For Treatment. We may use protected health information about you to provide you with, coordinate, or manage your medical treatment or services. We may disclose protected health information about you to doctors, nurses, technicians, students, or other our personnel, including persons outside of our office who are involved in your medical care.
Our staff may also share protected health information about you in order to coordinate your care for such
reasons as prescriptions, lab work, and x-rays.
For Health Care Operations. We may use and disclose protected health information about you for our health care operations, such as our quality assessment and improvement activities, case management, coordination of care, business planning, customer service, and other activities. These uses and disclosures are necessary to run the facility, reduce health care costs, and make sure that all of our clients receive quality care. For example, we use the HIPAA compliant web-based practice management and electronic medical record (EMR) Kalix for appointment scheduling, electronic record keeping and filing, electronic paperwork and coordination of care. Your protected health information is recorded, stored and transmitted in Kalix in an encrypted state. We may also combine protected health information about many of our clients to decide what additional services we should offer, what services are not needed, and whether certain treatments are effective. We review our treatment and services or to evaluate the performance of the practitioner who is providing your services. We may also disclose information to doctors, nurses, technicians, students, and other personnel for review and learning purposes.
Subject to applicable state law, the law allows or requires us to use or disclose your health information without
your authorization in some limited situations for purposes beyond treatment, payment, and operations.
As Required by Law. We will disclose protected health information about you when required to do so by federal, state, or local law.
Research. We may disclose your protected health information to researchers when their research has been
approved by an institutional review board or privacy board that has reviewed the research proposal and
established protocols to ensure the privacy of your information. We may permit researchers to review records to help identify patients who may be included in their research projects or for similar purposes as long as the
researchers do not remove or take a copy of any health information.
To Avert a Serious Threat to Health or Safety. We may use and disclose protected health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. We may also disclose protected health information about you to a government authority if we
reasonably believe that you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, and we will only disclose it if (a) you agree to the disclosure, or (b) the disclosure is allowed by law and we believe it is necessary to prevent or lessen a serious and imminent threat to you or another person.
Judicial and Administrative Proceedings. We may disclose your protected health information in response to a court or administrative order. We may also disclose your protected health information 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, either by us or the requesting party, to tell you about the request or to obtain an order protecting the information requested.
Business Associates. We may disclose information to business associates who perform services on our behalf
including our EMR and practice management solution Kalix and clearinghouse Office Ally. However, we require
that these associates appropriately safeguard your information. Our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
Public Health. As required by law, we may disclose your protected health information to public health or legal
authorities charged with preventing or controlling disease, injury, or disability.
Health Oversight Activities. We may disclose protected health information to a health oversight agency for
activities authorized by law. These activities include audits, investigations, and inspections, as necessary for
licensure and for the government to monitor the health care system, government programs, and compliance
with civil rights laws.
Law Enforcement. We may release protected health information as required by law, or in response to an order or warrant of a court, a subpoena, or an administrative request. We may also disclose protected health
information in response to a request related to identification or location of an individual, a victim of crime, a
decedent, or a crime on the premises.
Organ and Tissue Donation. If you are an organ donor, we may release protected health information to an organ donation bank or to organizations that handle organ procurement or organ, eye, or tissue transplantation, as necessary to facilitate organ or tissue donation and transplantation.
Special Government Functions. If you are a member of the armed forces, we may release protected health
information about you if it relates to military and veterans activities. We may also release your protected health
information for national security and intelligence purposes, protective services for the President, and medical
suitability or determinations made by the Department of State.
Coroners, Medical Examiners, and Funeral Directors. We may release protected health information to a
coroner or medical examiner. This release may be necessary, for example, to identify a deceased person or
determine the cause of death. We may also disclose protected health information to funeral directors, consistent with applicable laws, to enable them to carry out their duties.
Correctional Institutions and Other Law Enforcement Custodial Situations. If you are an inmate of a
correctional institution or under the custody of a law enforcement official, we may release protected health
information about you to the correctional institution or law enforcement official as necessary for your or another person’s health and safety.
Worker’s Compensation. We may disclose protected health information as necessary to comply with laws
relating to worker’s compensation or other similar programs established by law.
Food and Drug Administration (FDA). We may disclose to the FDA, or persons under the jurisdiction of the FDA, protected health information relative to adverse events with respect to drugs, foods, supplements, products, and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Fundraising and/or Marketing Communications. We may contact you about fundraising activities or to market health-related services or benefits. You have the right to opt-out of this type of communication by contacting us.
We will not sell your information to any third party.
Appointment Reminders, Treatment Alternatives, and Health-Related Benefits and Services. We may use and disclose protected health information in order to contact you (by email, telephone, voice message and/or text (SMS) message), as a reminder (including automated reminders sent via Kalix) that you have an upcoming appointment for treatment or medical care. We may use and disclose protected health options, treatment alternatives, or health-related benefits or services that may be of interest to you.
For Work-Related Injuries or Illnesses or Workplace Medical Surveillance. We may disclose health
information to tell you about or recommend possible treatment care information where your employer has a
duty under state or federal law, to keep records or act on such information.
Incidental Disclosures may occur as a by-product of permitted uses and disclosures of your health care
information. These incidental disclosures are permitted if we have applied reasonable safeguards to protect the confidentiality of your health care information.
Electronic Medical Record
To promote quality care, our operates an electronic medical record (EMR) Kalix. Our providers and some
providers unaffiliated with us may have access to the EMR. Your medical record may be comprised ofinformation in the EMR as well as in a paper record. We are legally obligated to notify any individual whose
protected health information is affected by a security breach.
You Can Object to Certain Uses and Disclosures
Unless you object, or request that only a limited amount or type of information be shared, we may use or
disclose protected health information about you in the following circumstances:
We may share with a family member, relative, friend or other person identified by you, protected health
information that is directly relevant to that person’s involvement in your care or payment for your care. We may
also share information to notify these individuals of your location, general condition, or death.
We may share protected health information with a public or private agency (such as the American Red Cross) for disaster relief purposes. Even if you object, we may still share this information if necessary under emergency
circumstances.
If you would like to object to use and disclosure of protected health information in these circumstances, please
call us.
Your Rights Regarding Protected Health Information About You
You have the following rights regarding protected health information that we maintain about you:
Right to Inspect and Copy. You have the right to inspect and copy protected health information that may be
used to make decisions about your care or payment for your care, including protected health information stored electronically, you can request that we provide access in an electronic format that is readily producible, or in a format agreed to by us.
To inspect and copy protected health information that may be used to make decisions about you, you must
submit your request in writing. If you request a copy of the information, we may charge a fee for the costs of
copying, mailing, or supplies associated with your request. We may not charge you a fee if you need the
information for a claim for benefits under the Social Security Act or any other state or federal needs-based
benefit program. We will respond to your request no later than 30 days after we receive it. There are certain
situations in which we are not required to comply with your request. In these circumstances, we will respond to
you in writing, stating why we will not grant your request and describe any rights you may have to request a
review of our denial.
Right to Amend. If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend or supplement the information.
To request an amendment, your request must be made in writing and submitted to us. In addition, you must
provide a reason that supports your request. We will act on your request for an amendment no later than 60
days after we receive it.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the
request. In these circumstances, we will provide a written denial stating why we will not grant your request. In
addition, we may deny your request if you ask us to amend information that:
-Was not created by us, unless the person or entity that created the information is no longer available to make
the amendment;
-Is not part of the protected health information kept by us;
-Is not part of the information that you would be permitted copy;
or -We believe is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of protected health information about you.
To request this list of disclosures, you must submit your request in writing. You may ask for disclosures made
within the six years before your request. The first list you request within a 12-month period will be free. For
additional lists in that 12-month period, we may charge you for the costs of providing the list. We are required to provide a list of all disclosures except the following:
Disclosures made for your treatment;
- Those used for billing and collection of payment for your treatment;
- Those related to health care operations;
- Those made to you or requested by you, or those that you authorized;
- Those that occurred as a byproduct of permitted use and disclosures;
- Those used for national security or intelligence purposes, or provided to correctional institutions or law
enforcement regarding inmates;
- Those that were a part of a limited data set of information that does not contain information identifying you.
Right to Request Restrictions. You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or health care operations, or to persons involved in your care.
We are 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, the disclosure is to the Secretary of the Department of Health and Human Services, or the disclosure is required by law. To request restrictions, you must make your request in writing.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing. We will accommodate all reasonable requests.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice at any time even if you have agreed to receive it electronically. We encourage you to read and ask questions about this Notice.
Right to Receive Notice of Breach. You have a right to be notified upon a breach of any of your unsecured
protected health information.
Rights for Out-of-Pocket Payments. If you paid out of pocket in full for a specific item or service, you have a right to ask that your protected health information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations. We are required to agree to your request unless the disclosure is otherwise required by law.
Types of Uses and Disclosures Requiring an Authorization
Most uses and disclosures of psychotherapy notes require us to obtain an authorization from you. In addition, in most instances, we cannot use or disclose your protected health information for marketing purposes or sell your protected health information without your written authorization. Finally, any other use or disclosure not
described in this Notice will be made only with your authorization. Any time you provide us with a written
authorization, you may revoke it any time in writing, to the extent that we have not already taken action in
reliance on your previous authorization.
Other Uses and Disclosures
We will obtain your written authorization before using or disclosing your protected health information for
purposes other than those described in this Notice (or as otherwise permitted or required by law). You may
revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or
disclosing your information, except to the extent that we have already taken action in reliance on the
authorization.
You May File a Complaint About Our Privacy Practices
If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the
Department of Health and Human Services. A complaint to the Secretary should be filed within 180 days of the
occurrence or action that is the subject of the complaint.
If you file a complaint, we will not take any action against you or change our treatment of you in any way.
Changes to This Notice
We reserve the right to change this Notice and make the new Notice apply to health information we already
have, as well as any information we receive in the future. We will post a copy of our current Notice in our office.