7130 Minstrel Way, Suite 160, Columbia, Maryland 21045, (410) 312 9922
This Notice of Privacy Practices describes how health information about you may be used and disclosed and how you can get access to your health information. All individuals receiving care may request a copy of this Notice of Privacy Practices for their records. Please review this information carefully.
Understanding your health record: A record is made each time you visit Awaken Wellness. Your symptoms, the practitioner's judgments, and a plan of treatment are recorded. This record serves as a basis for planning your care and treatment at future visits, and also serves as a means of communication among other health professionals who may contribute to your care. Understanding what information is retained in your record and how that information may be used will assist you to ensure it is accurate and make informed decisions about who, what, when, where, and why others may be allowed access to your health information.
Understanding your health information rights: Your health record is the physical property of Awaken Wellness, but the content is about you, and therefore belongs to you. You have the right to review or obtain a paper copy of your health record, and to request that appropriate amendments be made to your health record. You have the right to request restrictions on certain uses and disclosures of your information, to authorize disclosure of the record to others, and be given an account of those disclosures. Other than that activity that has already occurred, you may revoke any further authorizations to use or disclose your health information. Should we need to contact you, you have the right to request communication by alternate means or to alternate locations.
Our responsibilities: Awaken Wellness is required to maintain the privacy of your health information and to provide you with this notice of our privacy practices. We are required to follow the terms of this notice and to notify you if we are unable to grant your request to disclose or restrict disclosure of your health information to others. Awaken Wellness reserves the right to change its practices and promises to make a good faith effort to notify you of any changes. Other than for the reasons described in this notice, Awaken Wellness agrees not to use or disclose your health information without your authorization.
TO RECEIVE ADDITIONAL INFORMATION OR REPORT A PROBLEM, you may contact Awaken Wellness. If you believe your privacy rights have been violated, you have the right to file a complaint with us and/or with the U.S. Secretary of Health and Human Services with no fear of retaliation by this office.
A copy of this Notice of Privacy Practices will be provided to you upon written request.
I, , have read this Notice of Privacy Practices. I understand my health information will be used and disclosed consistent with this notice.
Signature of Witness: