Although medical spas in Texas are not required to comply with the Health Information Portability and
Accountability Act of 1996 (HIPAA,) Amerejuve Medspa & Cosmetic Surgery has voluntarily elected to try observe
the HIPAA guidelines when practical and feasible. Therefore our customary business practice is not use, or
discloses your personal health information without your authorization.
Privacy Policy and Procedures that our Medspa attempts to observe include the following:
All clients are presented with certain notices and must sign certain forms. Depending on the course of treatment,
some clients may require to sign additional forms. The following is a summary of the most common notices and
forms:
Authorization for use or disclosure of Protected Health Information: The Medspa may not use or disclose your
health information for purposes other than treatment, payment or health care operation, without your
authorization. Your signature on this form indicates that you are giving permission to the people listed on the
form, for the use and disclosure of the health information listed on the form, purposes on the form to the
people/organization listed on the form. You may revoke this authorization at any time by signing and dating the
revocation section on your copy of this form and returning it to this office.
Request to Amend Protected Health Information: You have the right to request that Health Information that
pertains to you be amended if you believe that it is incorrect or incomplete. The Medspa will review your request
and either grant your request or explain the reason why it will not be granted. In the event that your request is not
granted, you have the right to submit a statement of disagreement that will accompany the information in the
question for all future disclosure.
Request for Inspection of Protected Health Information: you have the right to request the opportunity to inspect
and copy health information that pertains to you. The Medspa will evaluate your request and will either grant it or
explain the reason why the request will not be granted. In the event that your inspection request is not granted,
you may request that the decision be reviewed by someone other than the person who denied the request.
Request for Accounting of Disclosure of Protected Health Information: You have a right to request an accounting
of disclosure of health information that pertains to you.
Confidential Channel Communication request: You have the right to request that communications concerning your
personal health information be made through confidential channel. The Medspa will do its best to accommodate
all reasonable requests.
Designation of Personal Representative: You have a right to nominate one or more persons to act on your behalf
with respect to the protection of health information that pertains to you. By making request, you are informing the
Medspa of your wish to designate the name person as your personal representative. You may revoke this
designation at any time by signing and dating the revocation of your copy of this form and returning it to this
office.

Acknowledgement Receipt of Notice of Privacy Practices:
I acknowledge that I have received and read the above Notice of Privacy Policy and Procedures and that I have had
any questions regarding this notice answered to my satisfaction. I understand that Amerejuve makes every effort
to follow these policies but is not required to comply with the HIPAA law. I understand that confidentiality of my
health and treatment-related information is not guaranteed.