Privacy Notice and Authorization for Non-Covered Entity
Exhibit B
Privacy is important and records will be held confidential unless the client signs a release to other caregivers or to obtain a client copy. The Functional Foodie Nutrition will not use or disclose your medical information for any purpose other than as provided by your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to The Functional Foodie Nutrition the address below. While The Functional Foodie Nutrition is not covered by the Health Insurance Portability and Accountability Act (“HIPAA”), the security of your health information is important and we take all reasonable steps to ensure the security of your information. Clients should be aware that there are limits to such protections.
Internet and Email Communication
If consultation occurs over Zoom or other video chat services, clients should understand that while its communications are encrypted, Zoom is not considered a secure patient web portal. No guarantee can be made that the Zoom or other service protects users’ data or the content of communications or that it is secure from third-party “hackers.” Further, e-mail is not a secure and confidential method of communicating health information. While The Functional Foodie Nutrition will take reasonable precautions with the information under their control, interception or misuse of client communications over Zoom, email, or telephone, while unlikely, are possible. Clients agree to assume the risk and accept the consequences of such breaches. The Functional Foodie Nutrition shall not be liable for any breach of confidentiality that may result from the use of e-mail.
E-mail should not be used for urgent matters and clients should contact 911 or visit the nearest emergency room if feeling unsafe or experiencing a life-threatening emergency. E-mail communications may be made part of my permanent health record and would be accessible to anyone given access to those records. Permission for communication via e-mail must be made by notice in writing. I hereby give permission for The Functional Foodie Nutrition to email nutritional recommendations and reply to my messages via e-mail, including any information that they deem appropriate, that would otherwise be considered confidential.
The Functional Foodie Nutrition may communicate my health information with Rebecca Snow Nutrition, LLC dba the Nutrition & Herbal Collective, including Rebecca Snow, MS, CNS, LDN and her contractors or employees retained for the purpose of supervision to allow for supervision of The Functional Foodie Nutrition Supervisor is bound by these same confidentiality principles and will not share client information. The security of any means of sharing information is done in a matter consistent with federal HIPAA requirements to provide reasonable assurances of privacy.
These authorizations shall be valid for one year from the date of our last attended visit unless otherwise indicated below. I understand that I may revoke this authorization in writing at any time, but that such revocation shall not be retroactive and I agree to hold The Functional Foodie Nutrition harmless with regard to any authorized release of information made before such revocation.
You should understand the following policies with regard to how we treat your personal health information:
1) We cannot release information to family members, other than parents or legal guardians, even if they are involved in your care, without your written permission.
2) In order to ensure quality of care, records are occasionally reviewed both internally and by outside consultants in legal, clinical, record keeping and other concerns that affect the quality of the services we provide. Only necessary information is accessed, and any such review is performed by professional staff working under the condition of confidentiality.
3) If you wish to limit the nature of information that is released, or the parties noted above to whom information may be provided, please inform Daniyal Ayvazian to discuss these limitations. In some instances, Daniyal Ayvazian may not be in a legal position to honor requested limitations, or there may be consequences that you need to be aware of, such as limitations upon receipt of insurance payment or upon the quality of care delivered. It is best to discuss any such concerns in advance.
4) You may revoke authorization for the future release of information in writing. We may in that event, however, decline to provide further treatment.
5) We may be required by law, in some cases, to make disclosures of your record that you have not authorized. Examples are subpoenas in criminal or civil litigation, or requests/surveys by licensure agencies or the U.S. Department of Health and Human Services.
6) Because Daniyal Ayvazian is not subject to HIPAA, Daniyal Ayvazian will continue long established and useful business practices, such as providing you with appointment reminders, notifying you of lab results, or using sign-in sheets, but will take steps to do so in a fashion that takes your privacy expectations into account. Please inform staff of any limitations you would like us to honor in this regard.
7) While the records of the care we provide are our property, we will make them available for your inspection and provide copies. Daniyal Ayvazian reserves the right to charge a reasonable fee.
The authorization on the following page allows us to request and obtain records from practitioners that you have seen for the purpose of assisting us in your consultation. If you wish records sent to a health provider you have not yet seen, a family member, an attorney, or other party outside of this list, you must first sign a release of information before we can forward your information.
Terms and Conditions for The Functional Foodie Nutrition Private Practice
Last Updated: 1/8/24
Welcome to The Functional Foodie Nutrition Private Practice. By accessing or using our website and services, you agree to comply with and be bound by the following terms and conditions. Please read these terms carefully.
1. Acceptance of Terms
By accessing and using the services provided by The Functional Foodie Nutrition], you agree to be bound by these terms and conditions. If you do not agree to all the terms and conditions, please do not use our services.
2. Services
The Functional Foodie Nutrition provides functional nutrition services for individuals seeking personalized nutritional guidance. Our services may include but are not limited to consultations, dietary plans, and nutritional education.
3. Client Responsibilities
Clients are responsible for providing accurate and complete information about their health, medical history, and dietary habits. The information provided will be used to tailor personalized nutrition plans.
4. Privacy Policy
We take your privacy seriously. Please refer to our Privacy Policy to understand how we collect, use, and protect your personal information.
5. Disclaimer
The Functional Foodie Nutrition provides general nutritional information and advice. Our services are not a substitute for professional medical advice, diagnosis, or treatment. Always consult with a qualified healthcare professional regarding your health conditions.
6. Payment and Fees
Payment for services is due at the time of booking or as otherwise agreed upon. Fees are subject to change, and any changes will be communicated in advance.
7. Cancellation and Refund Policy
Please refer to our Cancellation and Refund Policy for information on cancellations, rescheduling, and refunds.
8. Intellectual Property
All content and materials provided by The Functional Foodie Nutrition, including but not limited to text, graphics, logos, and images, are the property of The Functional Foodie Nutrition and are protected by intellectual property laws.
9. Governing Law
These terms and conditions are governed by the laws of Georgia. Any disputes arising from or relating to these terms and conditions will be subject to the exclusive jurisdiction of the courts in Georgia.
10. Changes to Terms and Conditions
The Functional Foodie Nutrition reserves the right to modify or update these terms and conditions at any time. It is your responsibility to check for updates periodically.
By using our services, you agree to these terms and conditions. If you have any questions or concerns, please contact us at thefunctionalfoodie4@gmail.com.
Thank you for choosing The Functional Foodie Nutrition for your functional nutrition needs.