HIPAA PRIVACY POLICY

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Understanding Your Medical Record and Your Health Information

Each time you receive treatment from our practice, information about your treatment is recorded in your medical record. Typically, this record consists of your medical history, symptoms, examination, observations, test results, diagnosis, treatment, and future care plans. Understanding your health information and how it is used helps to ensure that it is accurate, and that it is used and disclosed appropriately.

Your Health Information Privacy Rights

Although your medical record is the property of Bellatox Boutique/Lounge, the information belongs to you. You have legal rights regarding your health information, which are described below. To exercise any of these rights, a written request with supporting reasons, must be submitted to our Administrator. Requests that do not follow these guidelines may be denied.

Your legal rights include a:

• Right to Access. With some exceptions, you have the right to review and copy your health information. We may charge a fee for the cost of copying, mailing, or other supplies associated with your request.
• Right to Amend. You have the right to request an amendment of your health information when it is incorrect or incomplete. This right exists as long as we keep this information.
• Right to an Accounting of Disclosures. You have the right to obtain a listing of those to whom we disclosed your health information. This applies to disclosures other than those made for treatment, payment, health care operations and those you specifically authorized. You can request an accounting for up to 6 years prior to the date of the request. The first request in a 12-month period is provided at no cost to you. There may be a charge for subsequent requests within the same 12-month period.
• Right to Request Restrictions. You have the right to request restrictions on the use or disclosing of your health information. We will use our best efforts to comply with all approved requests except when the information is needed to provide emergency treatment. We will provide you with a written explanation for denied requests or when we revoke a previously to restriction.
• Right to Request Alternate Communications. You have the right to specify that communication with you be conducted in a particular manner or directed to a certain location. We will attempt to accommodate all reasonable requests.
• Right to a Paper Copy of this Notice. You may request a paper copy of this Notice at any time.
• Right to Require Written Authorization. Any uses or disclosures of your health information, other than those described below, will be made only with your advance written authorization, which you may grant or revoke at any time.

Use and Disclosure of Your Health Information

Federal privacy laws allow Bellatox Boutique/Lounge to use and disclose your health information for the following reasons or to the following entities:

• Treatment – Members of Bellatox Boutique/Lounge workforce (including doctors, nurses, aesthetician) may use your health information to treat and care for you. We many disclose your health information to providers, not affiliated with Bellatox Boutique/Lounge to facilitate the care they provide you. For example, we may disclose your health information to your personal physician or to the anesthesiologist during a surgical procedure.
• Payment – Members of Bellatox Boutique/Lounge workforce may use your health information to request payment for treatment we provide. For example, we may disclose your health information directly to you to request payment for the treatment we provide, or to your health insurance plan or a third party.
• Health Care Operations – Members of Bellatox Boutique/Lounge workforce may use your health information for health care operations of the Surgery Center. Examples of the activates are: state certification surveys, review of our services, determine effectiveness of new treatments, evaluate our performance, provide training to our staff, or to identify future services offerings and those no longer needed.
• Patient Communication – We may contact you to provide appointment reminders, alternative treatments, and other health services that may be of interest.
• Business Associates – We may disclose your information to service providers with whom we have contracted to provide a service on our behalf, written assurances must be in place, before disclosing your information to our Business Associates.
• Research – All research studies require internal approval before your health information is disclosed. We will obtain your authorization if the researcher requires access to information that identifies you.
• Lawsuits, Disputes, Law Enforcement – We may disclose your information in response to a court or administrative order, subpoena, warrant, summons, or discovery request.
• Funeral Directors, Coroners, Medical Examiners – We may disclose your health information in order for these individuals to carry out their duties.
• Food and Drug Administration (FDA), Public Health Agencies, Health Oversight Agencies – We may disclose your information to: report adverse events with food, drugs, medical devices, dietary supplements, other products and product recalls; report births, deaths, child abuse, neglect, domestic violence; prevent or control disease, injury, disability; notify people possibly exposed to a disease or maybe spreading a disease, authorized organ donations, or as required by law.
• Workers’ Compensation Programs.
• Correctional Institution – We may disclose your information when you are an inmate or under custody so the correctional institution can provide you health care, to protect your health and safety and that of others.
• Consumer information – is not shared with third-parties for marketing purposes
• Military Authorities – We may disclose your information when you are a member or veteran of the military

Our Responsibilities

It is our responsibility to:

• Provide reasonable safeguards in order to protect the privacy of your health information;
• Use or disclose the minimum amount of information required to reasonably provide necessary services;
• Provide and review this Notice with you regarding our legal duties and privacy practices with respect to your health information and to obtain your signature acknowledging receipt of this Notice;
• Post the current Notice in the Bellatox Boutique/Lounge, as well as on our website; and
• Abide by the terms of this Notice

We reserve the right to change our practices and to make the new provisions effective for all health information we maintain. This Notice will specify the effective date on the first page.

State Law Requirements

Some states have adopted more stringent restrictions on the use or disclosure of your health information than those described above. If there are additional requirements required by the Commonwealth of Kentucky or State of Indiana, then they will be included as an attachment to this notice.

Contacting the Privacy Contact for Bellatox Boutique/Lounge

If you have questions, or to exercise your rights, please contact the Administrator for the Bellatox Boutique/Lounge. If you believe your privacy rights have been violated, you may file a complaint with the Administrator (who is the Privacy Contact for Bellatox Boutique/Lounge) or you may file a written complaint with the Secretary of the Department of Health and Human Services. No retaliation will occur based on your filing a complaint.