Hair Mi Amour Flawless Crowns Cranial Prosthetic – HIPAA Privacy Acknowledgment & Consent

I acknowledge that Hair Mi Amour Flawless Crowns Cranial Prosthetic may collect, store, and use my protected health information (PHI) for the purposes of evaluation, consultation, treatment planning, provision of cranial prosthesis (medical wigs), insurance billing, reimbursement assistance, and related healthcare operations.

Protected health information may include, but is not limited to:

• Medical diagnoses related to hair loss
• Physician documentation or prescriptions
• Insurance information
• Photographs of the scalp or head (when applicable)
• Treatment notes and consultation records

Hair Mi Amour Flawless Crowns Cranial Prosthetic is committed to maintaining the privacy and security of my health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA). My information will not be disclosed to unauthorized individuals or entities without my written consent, except as permitted or required by law, including but not limited to insurance carriers, healthcare providers, or billing partners involved in my care.

I understand that:

• I have the right to request access to my records.
• I may request corrections to my health information.
• I may revoke this authorization in writing at any time, except where action has already been taken based on this consent.

By signing below, I acknowledge that I have read and understand this notice and consent to the use and disclosure of my protected health information as described above.

Notice of Privacy Practices & Authorization for Use and Disclosure of Protected Health Information

Effective Date: This notice is effective as of the date of client signature below.

1. Our Commitment to Your Privacy
Hair Mi Amour Flawless Crowns Cranial Prosthetic is committed to protecting the privacy of your health information. We are required by law to maintain the privacy of your protected health information (PHI), to provide you with this notice of our privacy practices, and to follow the terms of this notice currently in effect.

2. How We May Use and Disclose Your Health Information
We may use and disclose your PHI for the following purposes without requiring your additional authorization:

• Treatment: To provide, coordinate, and manage your care and treatment, including sharing information with other healthcare providers involved in your care.
• Payment: To obtain payment for services rendered, including billing your insurance company or other payer for cranial prosthesis services.
• Healthcare Operations: For internal administration, quality improvement, accreditation, licensing, and other business activities.
• As Required by Law: To comply with applicable federal, state, or local laws.
• Public Health Activities: To authorized public health authorities as required.
• Law Enforcement: To law enforcement officials as permitted or required by law.

3. Your Rights Regarding Your Health Information

• Right to Access: You have the right to inspect and receive a copy of your health information held by us, subject to limited exceptions. We may charge a reasonable fee for copying.
• Right to Amend: If you believe your health information is inaccurate or incomplete, you may request an amendment. We may deny the request under certain circumstances.
• Right to an Accounting of Disclosures: You have the right to request a list of certain disclosures of your PHI that we have made over the past six years.
• Right to Request Restrictions: You may request restrictions on how we use or disclose your PHI. We are not required to agree to all restrictions, except in limited circumstances.
• Right to Confidential Communications: You have the right to request that we communicate with you in a certain way or at a certain location.
• Right to Revoke Authorization: You may revoke any authorization you have provided at any time by submitting a written request. Revocation will not apply to actions already taken in reliance on your prior authorization.
• Right to a Paper Copy: You have the right to receive a paper copy of this Notice upon request.

4. Authorization for Release of Information
For uses and disclosures not covered by this Notice or permitted by law, we will ask for your written authorization. Your authorization is voluntary. You may revoke any authorization you give us in writing at any time. Revocation will not be effective for information we have already disclosed based on your authorization.

5. Changes to This Notice
We reserve the right to change this Notice and the terms of our privacy practices. Any changes will apply to PHI we already hold, as well as new information received in the future. The current Notice will always be posted in our office and available upon request.

6. Complaints
If you believe your privacy rights have been violated, you may file a complaint with Hair Mi Amour Flawless Crowns Cranial Prosthetic or with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint. To file a complaint with us, contact:

• Hair Mi Amour Flawless Crowns Cranial Prosthetic
• 966 Eagles Landing Parkway, Stockbridge, GA 30281
• Phone: (678) 782-5082 | (404) 893-8909
• Email: charm@charmamourhairrestoration.com

7. Acknowledgment of Receipt
By signing this form, I acknowledge that I have received and read (or had the opportunity to read) this Notice of Privacy Practices. I understand my rights as described and authorize Hair Mi Amour Flawless Crowns Cranial Prosthetic to use and disclose my protected health information as described in this Notice and for the purposes of providing cranial prosthesis services and related care.