HIPPA

Background

The Health Insurance Portability and Accountability Act of 1996 (HIPPA) requires health care providers, such as Balanced Health & Fitness, Inc., to notify clients about their policies and practices to protect the confidentiality of patient health information. This notice tells you about the ways Balanced Health & Fitness, Inc. may use and disclose health information about you, describes your rights, and states the obligations Balanced Health & Fitness, Inc. has regarding the use and disclosure of your health information.

Our Promise Regarding Your Health Information

The privacy policies and practices of Balanced Health & Fitness, Inc. protect confidential health information that identifies you or could be used to identify you and relates to a physical or mental health condition or the payment of your health care expenses. This individually identifiable health information is known as “protected health information” (PHI). Your PHI will not be used or disclosed without a written authorization from you, except as described in this notice or as otherwise permitted by federal and state health information privacy laws.

How Balanced Health & Fitness, Inc. May Use and Disclose Health Information About You

The following are the different ways Balanced Health & Fitness, Inc. may use and disclose your PHI without first having to obtain your written authorization:

For Treatment – Balanced Health & Fitness, Inc. may disclose your PHI to other licensed bodyworkers at Balanced Health & Fitness, Inc. We may also disclose your PHI to other health care providers not affiliated with Balanced Health & Fitness, Inc. who are providing you treatment, such as a physician, hospital, physical therapist, or nursing home.

For Health Care Operations – Balanced Health & Fitness, Inc. may use and disclose your PHI to enable it to operate or operate more efficiently. For example, Balanced Health & Fitness, Inc. may use your PHI to plan our future operations, for case management, to conduct compliance reviews, audits, quality assurance, licensure or certification requirements, or to evaluate our staff’s performance.

Other Benefits and Services – Balanced Health & Fitness, Inc. may use and disclose your PHI to tell you about possible treatment options or alternatives or other health related benefits or services that may be of interest to you. Balanced Health & Fitness, Inc. may use and disclose your PHI to remind you of appointments for health care services.

How Balanced Health & Fitness, Inc. May Use and Disclose Health Information About You If You Do Not Object

If you do not object, Balanced Health & Fitness, Inc. may disclose PHI to a close friend or family member involved in or who helps pay for your health care. In an emergency situation, Balanced Health & Fitness, Inc. may also disclose PHI to a disaster relief agency, such as the Red Cross, to help notify your friends or family of your location.

Special Uses and Disclosures

The law allows Balanced Health & Fitness, Inc. to use or disclose your PHI under the following circumstances without first having to obtain your written authorization:

As Required By Law – Balanced Health & Fitness, Inc. will disclose your PHI when required to do so by federal, state, or local law, including those laws that require the reporting of certain types of injuries or diseases.

Lawsuits and Disputes – If you become involved in a lawsuit or legal action, Balanced Health & Fitness, Inc. may disclose your PHI in response to court or administrative order, a subpoena, or search warrant.

Worker’s Compensation – Balanced Health & Fitness, Inc. may disclose your PHI authorized by and to comply with workers’ compensation laws.

Military and Veterans – If you are or become a member of the U.S. Armed forces, Balanced Health & Fitness, Inc. may release medical information about you if required by military command authorities.

To Avert Serious Threat to Health or Safety – Balanced Health & Fitness, Inc. may use and disclose your PHI when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person.

Public Health Risks – Balanced Health & Fitness, Inc. may disclose health information about you for public health activities. These activities include preventing or controlling disease, injury or disability; reporting births and deaths; reporting child abuse or neglect; or reporting reactions to medications or problems with medical products or to notify people of recalls of products they have been using.

Health Oversight Activities – Balanced Health & Fitness, Inc. may disclose your PHI to a health oversight agency for audits, investigations, inspections, and licensure necessary for the government to monitor the health care system and government programs.

National Security Services – Balanced Health & Fitness, Inc. may release your PHI to authorized federal officials for protection of the president or for national security and intelligence activities.

Organ and Tissue Donation – If you are an organ donor, Balanced Health & Fitness, Inc. may release your PHI to organizations that handle organ, eye, or tissue donation and transplantation.

Coroners, Medical Examiners, and Funeral Directors – Balanced Health & Fitness, Inc. may release your PHI to a coroner or medical examiner for identifying a deceased person or determining the cause of death. Balanced Health & Fitness, Inc. may also release your PHI to a funeral director, as necessary, to carry out his/her duties.

Your Rights Regarding Your Health Information

Your rights regarding the health information Balanced Health & Fitness, Inc. maintains about you are as follows:

Right to Inspect and Copy – You have the right to inspect and copy your PHI. To inspect and copy your health information, submit your request in writing to Balanced Health & Fitness, Inc. (see address below). Balanced Health & Fitness, Inc. assesses a fee of $15 for the cost of copying and/or mailing your request. In limited circumstances, Balanced Health & Fitness, Inc. may deny your request to inspect and copy your PHI. Generally, if you are denied access to your health information, you may request a review of the denial.

Right to Amend – If you think your health information Balanced Health & Fitness, Inc. has about you is incorrect or incomplete, you may ask to have it amended. To request an amendment, send a detailed request in writing to Balanced Health & Fitness, Inc.

Right to An Accounting of Disclosures – You have the right to request an “accounting of disclosures.” This is a list of disclosures of your PHI that Balanced Health & Fitness, Inc. has made to others, except for those necessary to carry out health care treatment, payment, or operations and disclosures you have authorized. To request an accounting of disclosures, submit your request in writing to Balanced Health & Fitness, Inc.

Right to Request Restrictions – You have the right to request a restriction on the health information Balanced Health & Fitness, Inc. uses or discloses about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information Balanced Health & Fitness, Inc. discloses about you to someone who is involved in your care or the payment for your care, like a family member or friend. To request restrictions, make your request in writing to Balanced Health & Fitness, Inc.

Note: Balanced Health & Fitness, Inc. is not required to agree to your request.

Right to Request Confidential Communications – You have the right to request that Balanced Health & Fitness, Inc. communicate with you about health matters, including reminder calls, in a certain way or at a certain location. For example, you can ask Balanced Health & Fitness, Inc. to call a specific number to remind you of your appointments. To request confidential communications, make your request in writing to Balanced Health & Fitness, Inc.

Note: Balanced Health & Fitness, Inc. is not required to agree to your request.

Right to a Paper Copy of this Notice – You have the right to a copy of this notice. You may write Balanced Health & Fitness, Inc. to request a written copy of this notice at any time.

Changes to this Notice

Balanced Health & Fitness, Inc. reserves the right to change this notice at any time and to make the revised or changed notice effective for health information Balanced Health & Fitness, Inc. already has about you. A copy of the current notice is available for review.

Complaints

If you believe your privacy rights under this policy have been violated, you may file a written complaint with Balanced Health & Fitness, Inc., Barry E. Myers, 103 E. Gregory Blvd., Kansas City, MO 64114. Alternatively, you may complain to the Secretary of the U.S. Department of Health and Human Services.

Note: You will not be penalized or retaliated against for filing a complaint.

Other Uses and Disclosures of Health Information

Other uses and disclosures of health information not covered by this notice or by the laws that apply to Balanced Health & Fitness, Inc. will be made only with your written authorization. If you authorize Balanced Health & Fitness, Inc. to use or disclose your PHI, you may revoke the authorization, in writing, at any time. If you revoke your authorization, Balanced Health & Fitness, Inc. will no longer use or disclose your PHI for the reasons covered by your written authorization; however, Balanced Health & Fitness, Inc. will not reverse any uses or disclosures already made in reliance on your prior authorization.

Contacts

If you have any questions about this notice, please contact:

Balanced Health & Fitness, Inc.

Barry E. Myers

103 E. Gregory Blvd.

Kansas City, MO 64114

816-589-3030

Effective Date: March 1, 2004