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 the information. Please review it carefully.

I, Lesley Lovely, understand that protected health information about you applies to all records of your care.
This notice will tell you the ways I may use and disclose protected health information about you. I will also describe your rights and certain obligations I have regarding the use and disclosures of protected health information. The law requires me to:
- Make sure that protected health information that identifies you is kept private
- notify you about how I protect health information about you
- explain how, when, and why I use and disclose your protected health information
- follow the terms at the Notice that is currently in effect
I am required to follow the procedures in this Notice. I reserve the right to change the terms of this Notice and to make new Notice provisions effective for all protected health information that I maintain by:
- posting the revised Notice in my office
- making copies of the revised Notice available upon request
HOW I MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU
The following categories describe different ways that I may use and disclose protected health information without your written authorization.
For Treatment. I may use protected health information about you to provide, coordinate or manage your medical treatment or services. I may disclose protected health information about you to doctors, nurses, technicians, or other personnel who are involved in taking care of you.
My staff may also share protected health information about you in order to coordinate the different things you need, such as prescription, lab work, and x-rays. I may also use and disclose protected health information to contact you as a reminder that you have an appointment for treatment or medical at the office of Lesley Lovely, MS, RD, CDE.
For Payment Services:
I may use and disclose protected health information about you so that the treatment and services you receive at the office of Lesley Lovely, MS, RD, CDE may be billed to and payment be collected from you, an insurance company or a third party. For example, I may need to give your health plan information about nutrition services you received at the office of Lesley Lovely, MS, RD, CDE so your health plan will pay me or reimburse you for the service. I may also tell your health plan about the nutrition services you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
As Required By Law:
I will disclose protected health information about you when required to do so by federal, state, or local law.
Business Associates.:
I may disclose information to business associates who perform services on my behalf such as billing companies, however they too are required to appropriately safeguard your information.
Health Oversight Activities.:
I may disclose protected health information about you 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 law.
Special Government Functions:
If you are a member of the armed forces I may release protected health information to organizations about you if it relates to military and veterans activities.
Worker's Compensation:
I may disclose information as necessary to comply with laws relating to worker's compensation or other similar programs established by law.
Worker's Compensation:
I may disclose information as necessary to comply with laws relating to worker's compensation or other similar programs established by law.
YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU
You have the following rights regarding protected health information I 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. Usually, this includes medical and billing records.
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.
I am not required by law to agree to your request. If I do agree, I will comply with your request unless the information is needed to provide you emergency treatment, or if the disclosure is to the Secretary of the Department of Health and Human Services.
Right to Request Confidential Communications.
You have the right to request that I communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that I only contact you at work or by e- mail. I will ask you to fill out a separate form stating your desired way with which to be communicated.
Right to a Paper Copy of This Notice.
You have the right to a paper copy of this Notice at any time by requesting it of me verbally or in writing.
PATIENT WRITTEN ACNKOWLEDGEMENT CONFIRMING RECEIPT OF PRIVACY NOTICE
I have received the HIPPA Privacy Notice.
Patient Signature
Date
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy