Privacy Policy

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.

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