Patient’s Acknowledgment and Consent

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Our Commitment to Your Privacy
At Reflective Body LLC, we are committed to maintaining the privacy and confidentiality of your personal health information (PHI). This notice explains our privacy practices, your rights, and our legal obligations regarding your PHI.

Uses and Disclosures of Health Information
Treatment, Payment, and Health Care Operations

We may use and disclose your PHI for the following purposes:
1. Treatment: To provide, coordinate, or manage your healthcare and any related services.
2. Payment: To obtain payment for services we provide to you.
3. Health Care Operations: For our business operations, such as quality assessment and improvement activities, auditing functions, and customer service.

Other Permitted and Required Uses and Disclosures
We may use or disclose your PHI in other situations without your authorization, as required by law or
for public health activities, legal proceedings, law enforcement purposes, and other similar functions.

Your Health Information Rights

The Right to Inspect and Copy
You have the right to inspect and copy your PHI that is contained in a designated record set for as long as we maintain the information. This right is subject to certain exceptions. You must submit your request in writing to the address below.
The Right to Request Restrictions
You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or healthcare operations. You also have the right to request a limit on the PHI we disclose to someone involved in your care or payment for your care. We are not required to agree to your request, but if we do, we will comply with it unless the information is needed to provide emergency treatment.
The Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will accommodate reasonable requests.
The Right to Amend
If you believe that your PHI is incorrect or incomplete, you may request an amendment. You must make your request in writing and provide a reason that supports your request. We may deny your request if the information was not created by us, is not part of the PHI kept by or for us, is not part of the information you would be permitted to inspect and copy, or is accurate and complete.
The Right to an Accounting of Disclosures
You have the right to request an accounting of disclosures. This is a list of the disclosures we made of your PHI for purposes other than treatment, payment, and healthcare operations, or those disclosures authorized by you.
The Right to a Paper Copy of This Notice
You have the right to obtain a paper copy of this notice upon request.

HIPAA
I understand that the Reflective Body LLC is authorized to release my medical records in accordance with Federal and Connecticut State Law, including the Health Insurance Portability and Accountability Act (HIPAA).

Complaints
If you believe your privacy rights have been violated, you can file a complaint with us at the address below or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.