Waiver and HIPAA Agreement

  1. Disclaimers
    1.1 I understand that the dietitians at The Tasty Balance are a Registered and Licensed Dietitian/Nutritionist and does not dispense medical advice nor prescribe treatment. Rather, she provides education to
    enhance my knowledge of health as it relates to foods, dietary supplements, and behaviors
    associated with eating. While nutritional and botanical support can be an important complement to
    my medical care, I understand nutrition counseling is not a substitute for diagnosis, treatment, or
    care of disease by a medical provider.
    1.2 If the Client is under the care of a healthcare professional or currently uses prescription
    medications, the Client should discuss any dietary changes or potential dietary supplement use
    with his or her primary care physician, and should not discontinue any prescription medications
    without first consulting his or her primary care physician.
    1.3 The Client acknowledges that the care that they receive during their nutrition and health
    coaching sessions is separate from the care that they receive from any medical facility in that the
    nutrition coaching session are in no way intended to be construed as medical advice or care. The
    client should continue regular medical supervision and care by their primary care physician.
    1.4 In consideration of my participation in Nutrition Counseling, I hereby accept all risk to my health
    and of my injury or death that may result from such participation and I hereby release Ariel
    Johnston, RD, LD, and dietitians at The Tasty Balance from any liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all illness or injury to my person, including my death, that may result from or occur
    during my participation in the Nutrition Counseling, whether caused by negligence of Ariel
    Johnston, RD, LD and dietitians at The Tasty Balance or otherwise. I further agree to indemnify and hold harmless Ariel Johnston, RD, LD and dietitians at The Tasty Balance from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in the described Nutrition Counseling session.
  2. Artificial Intelligence Use- The Tasty Balance uses a HIPPA compliance AI software to assist in medical charting. Client’s PHI is protected and doesn’t store client’s information or notes. Patient information is encrypted at-rest and in-transit. Patient recordings are never stored to disk and are immediately deleted upon successful note generation. All patient information is retained for a backup period of 30 days after which it is deleted.
  3. Personal Responsibility and Release of Health Care Related Claims
    2.1 The Client acknowledges that the Client takes full responsibility for the Client’s life and wellbeing, as well as the lives and well-being of the Client’s family and children (where applicable), and all decisions made during and after the duration of the client’s nutrition and wellness coaching sessions.
    2.2 The Client expressly assumes the risks of nutrition and wellness coaching sessions, including
    the risks of trying new foods, and the risks inherent in making lifestyle changes.
    2.3 The Client releases the Dietitian/Nutritionist and The Tasty Balance, LLC from any and all
    liability, damages, causes of action, allegations, suits, sums of money, claims and demands
    whatsoever, in lay or equity, which the Client ever had, now has or will have in the future against
    Ariel Johnston, RD, LD, and dietitians at The Tasty Balance arising from the Client’s past or future participation in, or otherwise with respect to, the nutrition sessions, unless arising from the gross negligence of the Dietitian/Nutritionist.
  4. Payments and Refunds
    3.1 Payments are due at the time of service and there are no refunds for payments made to
    Ariel Johnston and dietitians at The Tasty Balance.
  5. No-Show/Cancellation Policy
    4.1 In the event that the Client does not show up to an appointment or cancels within 48 hours of a
    scheduled appointment Ariel Johnston, RD, LD and dietitians at The Tasty Balance reserves the right to charge the client up to $145 payment fee.
    4.2 The above may be disregarded in the event of an emergency. HIPAA NOTICE OF PRIVACY PRACTICES. This notice outlines your protected health information, how it may be used, and what your rights are. Please review carefully and ask any questions prior to signing. Questions about this notice can
    be directed to The Tasty Balance Dietitian. OUR PLEDGE REGARDING PROTECTED HEALTH INFORMATION: We, The Tasty Balance Dietitian understand that protected health information about you and your health is personal. We are committed to protecting health information about you. This Notice
    applies to all of the records of your care generated by The Tasty Balance Dietitian, whether made
    by The Tasty Balance Dietitian personnel or your personal doctor or other health care provider. This
    Notice will tell you about the ways in which we may use and disclose protected health information
    about you. We also describe your rights and certain obligations we have regarding the use and
    disclosure of protected health information.
  6. The law requires us to:
  • make sure that protected health information that identifies you is kept private
  • notify you about how we protect protected health information about you
  • explain how, when and why we use and disclose protected health information
  • follow the terms of the Notice that is currently in effect.
    We are required to follow the procedures in this Notice. We reserve the right to change the terms of
    this Notice and to make new notice provisions effective for all protected health information that we
    maintain by:
  • posting the revised Notice in our office
  • making copies of the revised Notice available upon request
  • posting the revised Notice on our website.
    HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU
    The following categories describe different ways that we use and disclose protected health
    information without your written authorization.
    For Treatment: We may use protected health information about you to provide you with, coordinate
    or manage your medical treatment or services. We may disclose protected health information about
    you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking
    care of you. The Tasty Balance Dietitian staff may also share protected health information about
    you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays.
    We also may disclose protected health information about you to people outside The Tasty Balance
    Dietitian’s office who may be involved in your medical care. We may use and disclose protected
    health information to contact you as a reminder that you have an appointment for treatment or
    medical care at The Tasty Balance Dietitian. We may use and disclose protected health information
    to tell you about or recommend possible treatment options or alternatives or health-related benefits
    or services.
    For Payment for Services: We may use and disclose protected health information about you so that
    the treatment and services you receive at The Tasty Balance Dietitian may be billed to and payment
    may be collected from you, an insurance company or a third party. For example, we may need to
    give your health plan information about nutrition services you received at The Tasty Balance
    Dietitian so your health plan will pay us or reimburse you for the service. We may also tell your
    health plan about the nutrition services you are going to receive to obtain prior approval or to
    determine whether your plan will cover the treatment.
    For Health Care Operations: We may use and disclose protected health information about you
    for The Tasty Balance Dietitian health care operations, such as our quality assessment and
    improvement activities, case management, coordination of care, business planning, customer
    services and other activities. These uses and disclosures are necessary to run the facility, reduce
    health care costs, and make sure that all of our patients receive quality care. We may also combine
    protected health information about many The Tasty Balance Dietitian patients to decide what
    additional servicesThe Tasty Balance Dietitian should offer, what services are not needed, and
    whether certain new treatments are effective. We may also disclose information to doctors, nurses,
    technicians, medical students, and other The Tasty Balance Dietitianpersonnel for review and
    learning purposes. We may also combine the protected health information we have with protected
    health information from other health care facilities to compare how we are doing and see where we
    can make improvements in the care and services we offer. We may remove information that
    identifies you from this set of protected health information so others may use it to study healthcare
    and health care delivery without learning who the specific patients are. We may also contact you as
    part of a fundraising effort. Subject to applicable state law, in some limited situations the law allows
    or requires us to use or disclose your health information for purposes beyond treatment, payment,
    and operations. However, some of the disclosures set forth below may never occur at our facilities.
    As Required By Law: We will disclose protected health information about you when required to do
    so by federal, state or local law.
    Research: We may disclose your PHI to researchers when their research has been approved by an
    institutional review board or privacy board that has reviewed the research proposal and established
    protocols to ensure the privacy of your information.
    Health Risks: We may disclose protected health information about you to a government authority if
    we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only
    disclose this type of information to the extent required by law, if you agree to the disclosure, or if
    the disclosure is allowed by law and we believe it is necessary to prevent or lessen a serious and
    imminent threat to you or another person.
    Judicial and Administrative Proceedings: If you are involved in a lawsuit or dispute, we may
    disclose your information in response to a court or administrative order. We may also disclose
    health information about you in response to a subpoena, discovery request, or other lawful process
    by someone else involved in the dispute, but only if efforts have been made, either by us or the
    requesting party, to tell you about the request or to obtain an order protecting the information
    requested.
    Business Associates: We may disclose information to business associates who perform services on
    our behalf (such as billing companies); however, we require them to appropriately safeguard your
    information. Public Health. As required by law, we may disclose your protected health information
    to public health or legal authorities charged with preventing or controlling disease, injury, or
    disability.
    To Avert a Serious Threat to Health or Safety: We may use and disclose protected health
    information about you when necessary to prevent a serious threat to your health and safety or the
    health and safety of the public or another person.
    Health Oversight Activities: We may disclose health information to a health oversight agency for
    activities authorized by law. These activities include audits, investigations, and inspections, which
    may be necessary for licensure and for the government to monitor the health care system,
    government programs, and compliance with civil rights laws.
    Law Enforcement: We may release protected health information as required by law, or in response
    to an order or warrant of a court, a subpoena, or an administrative request. We may also disclose
    protected health information in response to a request related to identification or location of an
    individual, victims of crime, decedents, or a crime on the premises.
    Organ and Tissue Donation: If you are an organ donor, we may release protected health information
    to organizations that handle organ procurement or organ, eye or tissue transplantation or to an
    organ donation bank to facilitate organ or tissue donation and transplantation.
    Special Government Functions: If you are a member of the armed forces, we may release protected
    health information about you if it relates to military and veterans’ activities. We may also release
    your protected health information for national security and intelligence purposes, protective
    services for the President, and medical suitability or determinations of the Department of State.
    Coroners, Medical Examiners, and Funeral Directors: We may release protected health information
    to a coroner or medical examiner. This may be necessary, for example, to identify a deceased
    person or determine the cause of death. We may also disclose protected health information to
    funeral directors consistent with applicable law to enable them to carry out their duties.
    Correctional Institutions and Other Law Enforcement Custodial Situations: If you are an inmate of a
    correctional institution or under the custody of a law enforcement official, we may release protected
    health information about you to the correctional institution or law enforcement official as necessary
    for your or another person’s health and safety.
    Worker’s Compensation: We may disclose information as necessary to comply with laws relating to
    worker’s compensation or other similar programs established by law.
    Food and Drug Administration: We may disclose to the FDA, or persons under the jurisdiction of the
    FDA, protected health information relative to adverse events with respect to drugs, foods,
    supplements, products and product defects, or post marketing surveillance information to enable
    product recalls, repairs, or replacement.
    YOU CAN OBJECT TO CERTAIN USES AND DISCLOSURES. Unless you object, or request that
    only a limited amount or type of information be shared, we may use or disclose protected health
    information about you in the following circumstances:
  • We may share with a family member, relative, friend, or other person identified by you protected
    health information directly relevant to that person’s involvement in your care or payment for your
    care. We may also share information to notify these individuals of your location, general condition
    or death.
  • We may share information with a public or private agency (such as the American Red Cross) for
    disaster relief purposes. Even if you object, we may still share this information if necessary for the
    emergency circumstances.
    If you would like to object to use and disclosure of protected health information in these
    circumstances, please call or write to our contact person listed on page 1 of this Notice.
    YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU.
    You have the following rights regarding protected health information we maintain about you:
    Right to Inspect and Copy: You have the right to inspect and copy protected health information that
    may be used to make decisions about your care. Usually, this includes medical and billing records.
    To inspect and copy protected health information that may be used to make decisions about you,
    you must submit your request in writing to The Tasty Balance Dietitian. If you request a copy of the
    information, we may charge a fee for the costs of copying, mailing or other supplies associated with
    your request, and we will respond to your request no later than 30 days after receiving it. There are
    certain situations in which we are not required to comply with your request. In these circumstances,
    we will respond to you in writing, stating why we will not grant your request and describe any rights
    you may have to request a review of our denial.
    Right to Amend: If you feel that protected health information we have about you is incorrect or
    incomplete, you may ask us to amend or supplement the information. To request an amendment,
    your request must be made in writing and submitted to The Tasty Balance Dietitian. In addition, you
    must provide a reason that supports your request. We will act on the/ your request for an
    amendment no later than 60 days after receiving the request. We may deny your request for an
    amendment if it is not in writing or does not include a reason to support the request, and will
    provide a written denial to you. In addition, we may deny your request if you ask us to amend
    information that:
  • Was not created by us, unless the person or entity that created the information is no longer
    available to make the amendment
  • Is not part of the protected health information kept by The Tasty Balance Dietitian
  • Is not part of the information which you would be permitted to inspect and copy, or
  • We believe is accurate and complete.
    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 protected health information about you. To
    request this list or accounting of disclosures, you must submit your request in writing to The Tasty
    Balance Dietitian. You may ask for disclosures made up to six years before your request (not
    including disclosures made before June 25, 2014). The first list you request within a 12-month
    period will be free. For additional lists, we may charge you for the costs of providing the list. We are
    required to provide a listing of all disclosures except the following:
  • For your treatment
  • For billing and collection of payment for your treatment
  • For health care operations
  • Made to or request by you, or that you authorized
  • Occurring as a byproduct of permitted use and disclosures
  • For national security or intelligence purposes or to correctional institutions or law enforcement
    regarding inmates
  • As part of a limited data set of information that does not contain information identifying you
    Right to Request Restrictions: You have the right to request a restriction or limitation on the
    protected health information we use or disclose about you for treatment, payment or health care
    operations or to persons involved in your care. We are not required to agree to your request. If we
    do agree, we will comply with your request unless the information is needed to provide you
    emergency treatment, the disclosure is to the Secretary of the Department of Health and Human
    Services, or the disclosure is for one of the purposes described on pages 4-5. To request
    restrictions, you must make your request in writing to The Tasty Balance Dietitian.
    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. For example, you can ask
    that we only contact you at work or by mail. To request confidential communications, you must
    make your request in writing to The Tasty Balance Dietitian. We will accommodate all reasonable
    requests.
    Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice at any time
    by contacting The Tasty Balance Dietitian.
    OTHER USES AND DISCLOSURES
    We will obtain your written authorization before using or disclosing your protected health
    information for purposes other than those provide for above (or as otherwise permitted or required
    by law). You may revoke this authorization in writing at any time. Upon receipt of the written
    revocation, we will stop using or disclosing your information, except to the extent that we have
    already taken action in reliance on the authorization.
    YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES
    If you believe your privacy rights have been violated, you may file a complaint with The Tasty
    Balance Dietitian, or file a written complaint with the Secretary of the Department of Health and
    Human Services. A complaint to the Secretary should be filed within 180 days of the occurrence of
    the complaint or violation. If you file a complaint, we will not take any action against you or change
    our treatment of you in any way