Privacy Policy
Patient Information and Consent
At NuBalance Health, your privacy and the protection of your health information are of the utmost importance. This HIPAA Consent Form serves to inform you of your rights under the Health Insurance Portability and Accountability Act (HIPAA) and to obtain your authorization for the use and disclosure of your Protected Health Information (PHI).
By completing and submitting this consent form, you acknowledge and agree to the following:
Use of Information: NuBalance Health may use your PHI for treatment, payment, and healthcare operations, including scheduling appointments, communicating with healthcare professionals, processing payments, and conducting quality assessments.
Disclosure of Information: We may share your PHI with authorized personnel, healthcare providers, or third-party service vendors involved in your care, only as permitted by HIPAA regulations and bound by confidentiality agreements.
Patient Rights: You have the right to access, review, and request amendments to your PHI. You may also request limitations on certain uses or disclosures, and revoke this consent in writing at any time, unless actions have already been taken based on prior authorization.
Security Measures: Your information is safeguarded using secure technology and privacy protocols to ensure confidentiality and compliance with federal HIPAA requirements.
This consent form enables NuBalance Health to provide you with safe, efficient, and compliant care while respecting your legal rights and privacy preferences.
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy.
Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is available in the office.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services.
HIPAA provides certain rights and protections to you as the patient.
We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services.
We have adopted the following policies:
1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
7. We agree to provide patients with access to their records in accordance with state and federal laws.
8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.
Consent to Obtain Patient Medication History
Patient medication history is a list of prescriptions that healthcare providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history.
The collected information is stored in the practice’s electronic medical record system and becomes part of your personal medical records. Medication history is very important in helping providers treat your symptoms and/or illness properly and avoid potentially dangerous drug interactions. It is very important that you and your provider discuss all your medications in order to ensure that your recorded medication history is 100% accurate.
Some pharmacies do not make prescription history information available, and our medication history might not include drugs purchased without using our health insurance. Also, over-the-counter drugs, supplements, or herbal remedies that you take on your own may not be included. I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers.
By signing this consent form you are giving your healthcare provider permission to collect and share your pharmacy and your health insurer information about your prescriptions that have been filled at any pharmacy or covered by any health insurance plan. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health issues.
Patient Consent for Use and Disclosure of Protected Health
Information
I hereby give my consent for NuBalance Health to use and disclose my protected health information (PHI) to perform Treatment, Payment, and health care Operations (TPO). With this consent, the practice may call me to my home or other alternative location and leave a message by voice, email, text message, or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminder cards, patient statements and anything pertaining to my clinical care as long as they are marked “Personal and Confidential”.
By signing this form, I am consenting to allow the practice to use and disclose my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures upon my prior consent. If I do not sign this consent, or later revoke it, the practice may decline to provide treatment to me.
Complaints, Comments and Questions
NuBalance Health is committed to providing quality care and resolving any complaint, problem, question or unsatisfactory experience that might occur in connection with
medical or nutritional services. It is the policy at NuBalance Health that (i) if any person has a complaint, problem, unsatisfactory or negative experience related to our business, services or products, such person must bring the matter to our attention privately, by email, phone, or in person; and (ii) we will investigate any such matter and attempt in good faith, without any retaliation, to reasonably resolve the matter.
By registering, I/we agree to comply fully with this policy. This is my/our sole and exclusive remedy in connection with any complaint or problem or unsatisfactory or negative experience that I/we may have with NuBalance Health, services or products (other than remedies available in a court of law or pursuant to arbitration). I/we further agree not to publish, post, transmit, disclose or distribute (directly or indirectly), in or on any publicly available or accessible forum, newspaper, magazine, electronic publication, blog, website, online users’ group or similar device, document, medium, any negative, false or disparaging comment, belief opinion, experience or information (or that could reasonably be so construed), without prior written consent. I/we acknowledge and agree that these terms are reasonable and that any breach or violation of this paragraph will cause significant damage and expense that would be impossible or highly impractical to quantify and establish. Consequently, I/we agree that upon each breach or violation of this paragraph, I/we will be obligated, jointly or severally, to pay liquidated damages in the amount of $200 per day per violation until the breach or violation has been cured to satisfaction.
Telemedicine Informed Consent
Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.
1) I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
2) I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.
3) I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
4) I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment. I may revoke my right at any time by contacting NuBalance Health at 678-313-5106.
5) I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.
6) I understand that my health care information may be shared with other individuals for scheduling and billing purposes. I understand that I will be responsible for any costs that apply to my telemedicine visit.
7) I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits. I understand that this document will become a part of my medical record. By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand.
IF YOU ARE EXPERIENCING A LIFE-THREATENING SITUATION SUCH AS CONTEMPLATING SUICIDE, CALL 911 OR THE 988 SUICIDE & CRISIS LIFELINE AT 988.
If the situation is an emergency, call 911. In some situations, telehealth is not an appropriate method of care. If you require immediate or urgent care, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. Providers may not respond promptly to communications you submit through the Service. If you are not experiencing an emergency or do not require immediate or urgent care, you can communicate with Providers through the secure message service in the Service. If a technical failure prevents you from communicating with your Providers through the Service, you should call the following number: Phone: (M-F 9AM – 4PM EST).
OPEN PAYMENTS NOTICE
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical device, and biologics to physicians and teaching hospitals be made available to the public. The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at