Effective Date: November 2022
This notice describes how personal health information about you may be used and disclosed, and how you can obtain access to this information.
We respect patient confidentiality and only release personal health information about you in accordance with State and Federal law. This notice describes policies related to the use of the records of your care generated by Unleashed Relief.
Personal and health information is collected in several ways
- Information we receive from you
- Information we receive from other healthcare providers.
During the course of our relationship, we will likely use and disclose health information about you for treatment, payment and healthcare operations. You may specifically authorize us to use Protected Health Information for any purpose or to disclose your health information by submitting the authorization in writing. Such disclosures will be made to any personal representatives you choose to have your protected health information.
Unleashed Relief may use your health information for marketing communications, including birthday cards, newsletters, or appointment reminders by calls, text, emails, postcards, or letters. You may be sent information to support your health care, information about alternative treatments, and health-related services that may be of interest to you. Please know that if you do not wish to receive such communications, you must declare so in writing.
Your Protected Health Information may be disclosed without your consent or authorization, when required by law, as in the following instances:
- To a public health agency, for purpose such as controlling disease
- To the appropriate government authority in case of suspected child abuse or in other cases of suspected abuse, neglect, or domestic violence, information will be disclosed to the appropriate governmental authority, with your agreement or if required by law, if you are incapacitated, or if it appears necessary to prevent serious harm to you or others
- To health oversight authorities for regulatory, licensing, and other legal purposes
- In litigation, subject to certain requirements controlling the terms of the disclosure
- To law enforcement agencies, subject to applicable legal requirements and limitations
We may not disclose information about you for any other purpose without your written authorization, provided separately from your written consent.
- Upon written request you have the right to access, review or receive copies of your healthcare records. A reasonable fee may be charged for copies of your records.
- Upon written request you have the right to receive a list of items this office has disclosed about your healthcare information.
- You have the right to request this office place additional restrictions on disclosure of your Protected Health Information.
- You have the right to request that we amend your Protected Health Information, the request must be in writing.
- You have a right to receive all notices in writing.
If you have any questions, complaints or want more information, please contact Tyler Juranek, LMT at Unleashed Relief.
Complaints, about your privacy rights or how your privacy is handled at this office, can be directed to Tyler Juranek, LMT by calling or directing a letter to his attention. If you are not satisfied with how this office handles your complaint, you may submit a formal complaint to:
DHHS (Office of Civil Rights), 200 Independence Avenue, S. W., Room 509F HHH Building,
Washington, D. C. 20201
I have read, reviewed, understand, and agree to the Notice of Privacy Policies for healthcare and/or other services provided through this office. This office has attempted to provide each patient with a Notice of Privacy Policies.