HIPAA PATIENT ACKNOWLEDGMENT & AUTHORIZATION
Notice of Privacy Practices
I acknowledge that I have received and reviewed a copy of the Practice’s Notice of Privacy Practices explaining how the Practice will use and disclose my protected health information (“PHI”) for its treatment, payment, healthcare operations and other described and permitted uses and disclosures. I understand that I may contact the privacy officer designated on such notice if I have a question or complaint. I understand that this information may be disclosed electronically by the Practice and/or the Practice’s business associates. I understand that the Practice’s Notice of Privacy Practices may be revised from time to time and that I am entitled to receive a copy of the current or any revised Notice of Privacy Practices upon request. To the extent permitted by applicable law, I consent to the use and disclosure of my information for the purposes described in the Notice of Privacy Practices.
Authorization to Use PHI
I authorize the Practice and its agents to use and disclose my PHI among the Practice, its employee and agents, and/or myself for the purposes contained in the Notice of Privacy Practices and for my care and treatment, including:
Any third party payer covering my medical services;
Other health care professionals and institutions in the delivery of health care to me;
In response to a legally sufficient subpoena or court order;
Employees and agents of the Practice, to the degree necessary to facilitate the provision of health care services and payment for such services; and
Otherwise as may be required by applicable law.
Consent to Email, Cell Phone, or Text Message Usage for Appointment Reminders and Other Healthcare Communications
I consent to receiving by telephone call, text message, or voicemail transmission, communications by or on behalf of the Practice at the email, telephone number or text address that I have provided above or in any other patient record. I also consent to receiving such communications to any email, text address, or telephone number forwarded to or transferred from that address or telephone number. Healthcare communications include, but may not be limited to: healthcare communications to me or my designated representatives regarding my treatment, health, or conditions; reminder messages to me regarding appointments for medical care; communications regarding insurance, payments, collections, or billing requests; requests for feedback about my visit via satisfaction surveys and/or public reviews. I authorize and acknowledge that these instructions and other communications may be transmitted using an automated system for the selection or dialing of telephone numbers or the playing of prerecorded messages and may be made by the Practice or someone calling on its behalf.
Disclosures to Friends, Family, or Other Designated Representatives
If you would like to designate a friend, family member, or other individual with whom the provider may discuss your medical condition, please let provider know and they will note on your file.
Consent for Photographing or Other Recordings for Security and/or Health Care Operations
I consent to photographs, digital or audio recordings, and/or images of me being taken or recorded for the purposes my health care, security purposes, and/or for the Practice’s general health care operations. I understand that the Practice retains the ownership rights to the images and/or recordings. I will be allowed to request access to copies of the images and or recordings upon request.
Additional Acknowledgments
I understand that I may revoke or modify the authorizations contained herein in writing by contacting the privacy officer as stated in the Notice of Privacy Practices, except to the extent that information has already been disclosed based on this authorization.
I understand that the term “protected health information” or “PHI” is individually identifiable information about me, as the patient, and that it includes my past, present, or future healthcare and is transmitted and/or stored by a covered entity or business associate.
I have had the opportunity to place special restrictions upon the authorizations herein.
(Please let provider know if special restrictions need noted on this form)
I understand that this executed authorization will be stored in my medical record and will be available to me upon request. A copy of this authorization is considered as valid as the original. This authorization does not have an expiration date and will remain in effect until updated or revoked in writing.
I certify that I have read and fully understand the statements above on all pages and I consent fully and voluntarily to its contents.
NOTICE OF PRIVACY PRACTICES
Effective Date 5/1/2026
This Notice of Privacy Practices (the “Notice”) describes how medical information
about you, as the patient of the following medical practice:
Unwavering Health LLC may be used and disclosed, and how you can get access to this information. This Notice is required by the privacy regulations created under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Please read it carefully.
PRIMARY USES AND DISCLOSURES
This section describes the primary ways we use and/or share your health information.
We may use and disclose your health information about you in the following ways:
For Your Treatment. We can use your health information and share it with other health
care professionals who are treating you including, but not limited to: doctors, nurses,
technicians, health students, or other personnel who are involved in your medical
treatment and care. These other healthcare professionals may work at our Practice, at a
hospital if you are hospitalized under our supervision, at another doctor’s office, lab,
pharmacy, or other health care provider that we may refer you to for consultation or
treatment.
For Our Practice Operations. We can use and share your health information to run our
Practice, manage and improve your care, and contact you when necessary. We may
use your health information to review our provision of treatments and services and to
evaluate the performance of our staff. We may combine health information about many
patients, including you, to decide what additional services we should offer, what
additional services may be needed, whether new services and treatments are effective,
or to compare ourselves to other practices to see where we can make improvements.
In some cases, we may remove information that identifies you from this set of health
information so that others can use it for purposes of studying and analyzing health care
metrics and information.
For Payment Purposes. We can use and share your health information so that the
treatment and services you receive from us can be billed to and payment collected
from you, an insurance company, health plan, or other third party. We may need to
give your health plan information about your visit so they can pay or reimburse us for
the visit. We may also tell your health plan or third-party payer about a treatment you
are planning to receive in advance of your receiving such treatment in order to
determine if your plan will cover the treatment.
OTHER PERMITTED USES AND DISCLOSURES
We are also allowed, or may be required to share your information, in other ways,
which include the following:
For Public Health Purposes. We can share your health information in certain public
health situations such as:
• To prevent disease
• To assist with product recalls
• To report adverse reactions to treatments or medications
• To prevent or reduce a serious threat to anyone’s health or safety
As Required by Law & Legal Proceedings. We will share your health information if
local, state, or federal law requires it, including, without limitation if the Department of
Health and Human Services requests it to ensure we are complying with federal privacy
laws. We may also disclose your health information when we are legally required to do
so for any judicial or administrative proceeding, in response to an order of a court or
administrative tribunal, or in certain conditions in response to a subpoena, discovery
request or other lawful purposes.
For Purposes of Health Oversight. We may disclose your health information to health
oversight agencies for activities authorized by law, such as audits, investigations, and
inspections. Oversight agencies seeking this information may include government
agencies that oversee the health care system, government benefit programs, other
government regulatory programs.
In Relation to Communicable Diseases. We may disclose your health information, if
authorized by law, to a person who may have been exposed to a communicable
disease or otherwise may be at risk of contracting or spreading the disease or
condition.
In Cases of Abuse or Neglect. We may disclose your health information to a public
health authority that is authorized by law to receive reports of child abuse, domestic
violence, or neglect. In addition, we may disclose your health information if we believe
that you have been a victim of abuse, domestic violence, or neglect to the
governmental entity or agency authorized to receive such information.
As Required by the Food and Drug Administration. We may disclose your health
information to a person or company required by the Food and Drug Administration
(“FDA”) for the purpose of quality, safety, or effectiveness of FDA-regulated products
or activities including, without limitation, reporting of product defects or problems,
adverse reactions and/or events, biologic product deviations, product tracking
purposes, to aid in product recalls, to aid in making repairs or replacements, or for
conducting post marketing surveillance, as such may be required.
For Research Purposes. We can use or share your information for health research
purposes.
In Response to Organ and Tissue Donation Requests. We can share your health
information with organ procurement organizations.
To Work with a Medical Examiner or Funeral Director. We can share your health
information with a coroner, medical examiner, or funeral director in the event of your
death.
To Address Workers’ Compensation, Law Enforcement, and Other Government
Requests. We can use or share your health information:
• For workers’ compensation claims
• For law enforcement purposes or in working with a law enforcement official
• For special government functions such as military, national security, and
presidential protective services
• With health oversight agencies for activities as authorized by law
In Relation to Military Personnel and Veterans. If you are a member of the armed
forces or separated/discharged from military services, we may release your health
information as required by military command authorities or the Department of Veterans
Affairs as may be applicable. We may also release your health information about
foreign military personnel to the appropriate foreign military authorities.
YOUR RIGHTS
When it comes to your health information, you have certain rights. This section explains
your rights. You have the right to:
Get a copy of this Notice. You can ask for a paper copy of this notice at any time and
one will be provided to you, even if you have agreed to receive the notice
electronically.
Get an electronic or paper copy of your medical record. You can ask to see or get an
electronic or paper copy of your medical record and other health information we have
about you. To do this, you can contact our Privacy Officer as listed at the end of this
Notice. We will provide a copy or a summary of your health information, usually within
30 days from the date of your request. We may charge you a reasonable, cost-based
fee.
Ask us to correct your medical record. You can ask us to correct your health
information if you think it is incorrect or incomplete. You can submit this request to our
Privacy Officer. We may deny your request, but we will tell you the reason for the
denial by sending you a written letter within 60 days.
Request confidential communications. You can ask us to contact you in a specific way
(for example, at a home or office phone) or to send mail to a different address. We will
comply with all reasonable requests.
Ask us to limit what we use or share. You can ask us not to use or share certain health
information for treatment, payment, or our operations. We are not required to agree to
your request, and we may deny your request if we determine that it would affect your
care. If you pay for a service or health care item out-of-pocket in full, you can ask us not
to share that information for the purpose of payment or our operations with your health insurance company. We will comply with such a request unless a law requires us to share that information.
Get a list of those with whom we’ve shared information. You can ask for a list of all
the times we have shared your health information over the past six years, which will
include who we shared it with and why we shared it. In response, we will include all
disclosures made except for those about treatment, payment, health care operations,
and disclosures requested by you. We will provide this list to you for free once per
year, but any additional requests will be charged at a reasonable, cost-based fee.
Choose someone to act for you. If you have given someone medical power of
attorney to act on your behalf or if someone has been appointed as your legal
guardian, that person can exercise your rights and make choices about your health
information. We will check the validity of such authorization or appointment and will
make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated. You can file a complaint if you
feel we have violated your rights regarding your health information by contacting our
Privacy Officer. You can also file a complaint with the U.S. Department of Health and
Human Services Office for Civil Rights by sending a letter to 200 Independence
Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf
We will not retaliate against you for filing a complaint.
YOUR CHOICES
With respect to some of your health information, you can tell us your choices about
what we share. If you have a clear preference for how we share your information in the
situations described below, please contact the Privacy Officer. You can tell us what you
want us to do, and we will follow your instructions.
You have the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
If the event you are not able to tell us your preference (for example, you are
unconscious or incapacitated), we may share your health information if we believe it is
in your best interest. We may also share your health information when needed to
lessen a serious and imminent threat to health or safety.
We will never share your information unless you give us your prior written consent in
the following cases:
• Marketing purposes
• Sale of your health information
• Most sharing of psychotherapy notes
With respect to fundraising, we may contact you for fundraising efforts, but you can tell
us not to contact you again.
OUR RESPONSIBILITIES
This section describes our responsibilities with respect to your health information.
• We are required by law to maintain the privacy and security of your protected
health information.
• We will not use or share your health information other than as described in this
Notice, unless you authorize us to do so in writing. If you authorize disclosures of
your health information outside of those described in this Notice, then you may
change your mind at any time by informing us in writing by contacting the
Privacy Officer.
• We will let you know promptly if a breach occurs that may have compromised
the privacy or security of your health information.
• We must follow the duties and privacy practices described in this Notice.
• We must give you a copy of this Notice.
• We can change the terms of this Notice, and the changes will apply to all
information we have about you. The new notice will be available upon request,
in our office, and on our website (as applicable).
PRIVACY OFFICER
If you have questions, concerns, complaints, or other requests, you should contact our
Privacy Officer as follows:
Shelby Johnson FNP
shelby@unwaveringhealth.org
937-765-0010