HIPAA Disclosure

/ HIPAA Disclosure

Notice of Privacy Practices

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 Office uses health information about you for treatment, to obtain payment for treatment, for administrative purposes, to evaluate the quality of care that you receive. Your health information is contained in a medical record that is the physical property of Bespoke Beauty.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to you past, present, or future physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by accessing our website at www.bespokebeautymt.com, calling our office and requesting that a revised copy be sent to you in the mail, or asking for one at the time of your next appointment.

How Our Office May Use or Disclose Your Health Information

Following are examples of the types of uses and disclosures of your health care information that our Office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.

For Treatment

We may use and disclose your health information to provide you with medical treatment or services or to manage your health care and any related services. For example, information obtained by a health care provider, such as a physician, nurse, or other person providing health services, to you, will record information in your record that is related to your treatment. This information is necessary for health care providers to determine what treatment you should receive. Health care providers will also record actions taken by them in the course of your treatment and note how you respond to the actions. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance to use with your health care diagnosis or treatment.

For Payment

Our Office may use and disclose your health information to others for purposes of receiving payment for treatment and services that you receive. For example, a bill may be sent to you or a third-party payer, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment. This may also include certain activities that your health insurance plan requires to be undertaken before it approves or pays for the health care services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant health information be disclosed to the health plan to obtain approval for the hospital admission.

For Healthcare Operations

We may use and disclose health information about you in order to support the business activities of our Office. For example, your health information may be disclosed to members of the medical staff, risk or quality improvement personnel, and others to:

o   Evaluate the performance of our staff;

o   Assess the quality of care and outcomes in your case and similar cases;

o   Learn how to improved our facilities and services; and

o   Determine how to continually improve the quality and effectiveness of the health care we provide.


Our Office may use your information to provide appointment reminders to you or information about treatment alternatives or other health-related benefits and services that may be of interest to you. In addition, when you arrive at our Office, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician and/or your appointment time. We may also call you by name in the waiting room when you physician is ready to see you.

Group Health Plans

A group health plan, health insurance issuer, or HMO with respect to a group health plan may disclose health information to the sponsor of the plan.

Required by Law

Our Office may use and disclose information about you as required by law. For example, our Office may disclose information for the following purposes:

o   For judicial and administrative proceedings pursuant to legal authority;

o   To report information related to victims of abuse, neglect or domestic violence; and

o   To assist law enforcement officials in their law enforcement duties.

Public Health

Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability or for other health oversight activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Coroners, Funeral Directors, and Organ Donation

We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death of for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Your health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.


Our office may use your health information for research purposes when an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information has approved the research.

Health and Safety

Your health information may be disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law. For example, we may disclose your health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Government Functions

Your health information may be disclosed for specialized government functions such as protection of public officials or reporting to various branches of the armed services.

Workers’ Compensation

Your health information may be used or disclosed in order to comply with laws and regulations related to Workers’ Compensation and other similar legally established programs.
Inmates. We may use or disclose your protected health information if you are an inmate of correctional facility and your physician created or received your protected health information in the course of providing care for to you. Business Associates. We will share your health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of you protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

Uses and Disclosures That We May Make Unless You Object

Family or Friends involved in Your Healthcare

Unless you object in writing, the health care professionals, using their best judgment, may disclose to a member of your family, a relative, a close friend or any other person you identify, your health information that directly relates to that person’s involvement in your health care. If you are unable to object to such disclosure, we may disclose such information is necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose your health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Other Uses

Other uses and disclosures will be made only with your written authorization, unless otherwise permitted or required by law, and you may revoke the authorization except to the extent that our Office has acted in reliance on it.

Required Uses and Disclosures

Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.

Your Health Information Rights

Although your health record is the physical property of our Office, the information belongs to you. Under the Federal Privacy Rules, 45 CFR Part 164, you have the right to:

o   Request a restriction on certain uses and disclosures of you information as provided by 45 CFR 164.522; however, our Office is not required to agree to your requested restriction, except if you pay for a service out-of-pocket in full and ask us not to share information for the purpose of payment with your health insurer.

o   Obtain a paper copy of the notice of our information practices upon request

o   Inspect and obtain a copy of your health record as proved in 45 CFR 164.524;

o   Request an amendment to your health record as provided in 45 CFR 164.526; however, we are not required to do so;

o   Request confidential communications from us by alternative means or at alternative locations;

o   Revoke your authorization to use or disclose health information except to the extent that action has already been taken; and

o   Receive an accounting of disclosures made of your health information for purposes other than treatment, payment, health care operations as described in this Notice of Privacy Practices and as provided in 45 CFR 164.528, subject to certain exceptions, restrictions and limitations.

Our Responsibilities
We are required by the Federal Privacy Rules to:

Maintain the privacy of protected health information;

o   Provide you with this notice of our legal duties and privacy practices with respect to your health information;

o   Abide by the terms of this notice;

o   Notify you if we are unable to agree to a requested restriction on how your information is used or disclosed;

o   Accommodate reasonable requests you may make to communicate health information for reasons other than those listed above and permitted under law.
We reserve the right to change our information practices and to make the new provisions effective for all protected health information it maintains including health information created or received prior to the effective date of any such revised notice. Should our health information practices change, we will post it in our Office and/or on our website, and/or provide you a copy of the revised notice, upon request.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting our Privacy Officer:

Bespoke Beauty

Attn: Privacy Officer

2100 Stephens Ave, Ste 104 Missoula, MT 59801

You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy /hipaa/complaints/.

We will not retaliate against you for filing a complaint.

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