Institute for Beauty, Wellness & Regenerative Medicine

Confidential Channel Communication Request

As required by the Health Information Portability and Accountability Act of 1996 you have a right to request that communications concerning your personal health information be made through confidential channels. This medical practice will not ask you why you are making your request and will make every effort to accommodate all reasonable requests. Some method of contact must be provided, and as appropriate, information as to how payment will be handled.

I, _______________________________________________ (print name) hereby request the use of the following confidential channels for the communication of information related to my personal health or treatment. This request supersedes any prior request for confidential channel communications I have made.

What telephone number(s) may we use to contact you? 	___________________________________________________
            
What email address may we use for correspondence?    ____________________________________________________

Please circle your choice response to the following questions: 

May we leave messages concerning your appointments/treatment with a co-worker, receptionist, or secretary that regularly answers your calls? 								Yes 	No 

May we leave messages on a voice mail at work? 					Yes 	No 

May we leave messages on an answering machine at home? 				Yes 	No 

May we leave information with a spouse or significant other? 				Yes 	No 

Is there anyone that is not listed above that we can give information to? If so, please specify. 															Yes	 No
Name _________________________________________ Relationship _____________
Name _________________________________________ Relationship _____________

For any children above 18, still living at home, may we discuss your appointments/treatments? 															Yes 	No 

You must inform us, in writing, of any changes in your directives. This record takes effect January 1, 2009 and will be kept in your file along with your acknowledgment of receipt of our Notice of Privacy Practices. 

I hereby acknowledge that I have been presented with a copy of the Institute for Beauty, Wellness & Regenerative Medicine’s Notice of Privacy Practices.

Patient Name: ____________________________________ Date: ____________
(Please print)
Signature: _______________________________________
(If minor or disabled, Legal Guardians signature)

NOTICE OF PRIVACY PRACTICES

To our patients. This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Our commitment to your privacy
Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information:

Use and disclosure of your health information in certain special circumstances
The following circumstances may require us to use or disclose your health information:

1. To public health authorities and health oversight agencies that are authorized by law to collect information.

2. Lawsuits and similar proceedings in response to a court or administrative order.

3. If required to do so by a law enforcement official.

4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.

5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

6. To federal officials for intelligence and national security activities authorized by law.

7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.

8. For Workers Compensation and similar programs.

Your rights regarding your health information

1. Communications. You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.

2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to the Institute for Beauty, Wellness & Regenerative Medicine.

4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in
writing and submitted to the Institute for Beauty, Wellness & Regenerative Medicine. You must provide us with a reason that supports your request for amendment.

5. Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact our receptionist.

6. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint please contact  your privacy officer at (405)271-5493 or privacyofficer@health.ok.gov  for further information. All complaints to our office must be submitted in writing.  You will not be penalized for filing a complaint.

7. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.
If you have any questions regarding this notice or our health information privacy policies, please contact the Institute for Beauty, Wellness & Regenerative Medicine at 918-939-8339 or contact your Privacy Officer at (405)271-5493 for further information.