The privacy of your medical information, as described in the HIPPA Privacy Act, is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice. We may use medical information about you to doctors, nurses, technicians, medical students or other health care providers to assist them in treating you. We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information.
Smart Wellness, LLC
State law allows any person to provide nutritional advice or give advice concerning proper nutrition – which is the giving of advice as to the role of food and food ingredient, including dietary supplements. This state law and Smart Wellness LLC does NOT confer authority to practice medicine or to undertake the diagnosis, prevention, treatment, or cure of any disease, pain, deformity, injury, or physical or mental condition and specifically does not authorize any person other than one who is licensed health practitioner to state that any product might cure any disease, disorder, or condition.
I am solely responsible for the decision to see Trisha Howell MSH RD LDN HHC for Medical Nutritional Therapy. I recognize that some recommendations may not prove to be successful. I understand some recommendations may be novel. I agree to participate in an active manner, monitor my progress, and report any concerns to Trisha Howell MSH RD LDN HHC or her staff. I also understand that any significant symptoms should be reported to my doctor. It is also recommended that I discuss the use of any nutritional supplements with my doctor before implementing.
I, the patient, hereby authorize the use or disclosure of my health information from the listed Health Practitioner as described below to the requesting practitioner.
REVOCATION: This authorization may be revoked in writing by the undersigned at any time prior to the release of information from the disclosing party. Written revocation will not affect any action taken in reliance on this authorization before the written revocation was recieved.