Message
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Please note: Requests will be resolved within 72 hours. All prescriptions are electronic and will be sent directly to your pharmacy.
HIPPA & Privacy Notice
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The health information that you provide is under the protection of the federal Health Insurance Portability and Accountability Act (HIPAA). We can use your health information for purposes of treatment, payment and health care operations. Under HIPAA, you have the right to Request restrictions on how we use or disclose your health information in certain circumstances, including for treatment, payment or health care operations. We do not have to agree to your request unless you request restriction on disclosures to a health plan for purposes of payment or healthcare operations, and the health information relates to an item or service for which you, or another person on your behalf, have assumed full financial responsibility. If we do agree to your restrictions, we will be bound by our agreement except in limited circumstances, such as if there is an emergency.
This form provides notice on how Ivory Lotus Therapy protects your confidential information. This notice describes how medical information about you may be used and disclosed as well as how you can get access to this information. Please review this information carefully. A copy of this form will be provided to the client if requested.
By signing below, you are allowing us to contact the pharmacy for your prescription refill request.
Ivory Lotus Therapy
2700 University Ave Suite 308 | WDSM | IA | 50266
Phone: 515-650-2454
HIPAA NOTICE OF PRIVACY PRACTICES
[EFFECTIVE January 1, 2025]
Note: If you have questions about this Notice, please contact Ivory Lotus Therapy. We may be contacted at: 515-650-2454. lf you have questions regarding your clinical records, please call the number listed below.
WHO WILL FOLLOW THIS NOTICE:
This notice describes the privacy practices of Ivory Lotus Therapy.
All employees of Ivory Lotus Therapy as well as any health care professional who is authorized to enter information into your chart may have access to information in your chart for treatment, payment and health care operations, and may use and disclose information as described in this Notice. This Notice also applies to any volunteer or trainee we allow to help you while seeking services from us.
OUR PLEDGE REGARDING MEDICAL INFORMATION
Your medical information includes information about your physical and mental health. We understand that information about your physical and mental health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at Ivory Lotus Therapy. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by us. This Notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We reserve the right to revise or amend our Notice of Privacy Practices without additional notice to you. Any revision or amendment of this Notice will be effective for all of your records we have created or maintained in the past, and for any of your records we may create or maintain in the future. We will post a copy of our current Notice and any amended Notice on our public website and keep a paper copy at Ivory Lotus Therapy.
OUR OBLIGATIONS TO YOU
We are required by law to:
Make sure that medical information that identifies you is kept private except as otherwise provided by state or federal law;
Give you this Notice of our legal duties and privacy practices with respect to medical information about you; and
Follow the terms of the Notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:
Ivory Lotus Therapy continues to follow disclosure procedures in adherence to Iowa Code Chapter 228 Disclosure of Mental Health and Psychological Information. Iowa law is more stringent regarding disclosure of protected health information and therefore takes precedence over the federal procedures.
The following categories describe different ways that we may use and disclose medical information about you without your consent or authorization. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. The Notice covers treatment, payment, and what are called health care operations, as discussed below. It also covers other uses and disclosures for which a consent or authorization are not necessary. Where Iowa law is more protective of your medical information, we will follow state law, as explained below:
For Treatment: Once you have signed the acknowledgement provided with this Notice, we may use medical information about you to provide you with medical treatment or services unless otherwise required by applicable Iowa law. We may disclose medical information about you to doctors, nurses, medical students, pharmacists or other health care providers, who are involved in taking care of you whether or not they are affiliated with Ivory Lotus Therapy. For example, we may disclose medical information about your physical health to your family physician or hospital or other entity that has or will provide treatment or health care to you. Ivory Lotus Therapy continues to require an authorization of disclosure in order to disclose specific mental health, substance abuse or HIV/AIDS related information as required by applicable Iowa law and federal regulations.
During the course of your treatment, we may refer you to other health care providers such as independent laboratories with which you may not have direct contact These providers are called "indirect treatment providers." "Indirect treatment providers" are required to comply with the privacy requirements of Iowa and federal law and keep your medical information confidential.
For Payment: We may use and disclose medical information about you so that the treatment and services you receive at Ivory Lotus Therapy 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 treatment received so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment
Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations,
Inspections and licensure: These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Administrative Procedures: If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved ln the dispute, but only if efforts have been made to tell you and your attorney about the request or to obtain an order protecting the information requested. In addition, we may disclose medical information, including mental health treatment information, to the opposing party in any lawsuit or administrative proceeding where you have put your physical or mental condition at issue.
Law Enforcement: We may release medical information if asked to do so by a law enforcement official:
In response to a court order, subpoena, warrant, summons or similar process;
To identify or locate a suspect, fugitive, material witness, or missing person;
about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
about a death we believe may be the result of criminal conduct;
about criminal conduct at Ivory Lotus Therapy or its affiliates; and
in emergency circumstances to report a crime; the location of the
crime or victims; or the identity, description or location of the person who committed a crime.
Coroners Medical Examiners and Funeral Directors: We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others: We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
For Health Care Operations: We may use and disclose medical information about you for "health care operation," These uses and disclosures are necessary to operate Ivory Lotus Therapy and make sure that all of our clients receive quality care. For example, we may use medical information or mental health treatment information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also disclose such information to doctors, nurses, medical students and other Ivory Lotus Therapy employees or consultants for review and learning purposes.
Appointment Reminders: Unless you tell us otherwise in writing, we may use and disclose medical information to contact you as a reminder that you have an appointment for treatment at Ivory Lotus Therapy.
Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. However, we will not use or disclose medical information to market other products and services, either ours or those of third parties, without your authorization.
Health-Related Benefits and Services: We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care: We may release medical information, including mental health information, about you to a family member who is involved in your medical care without consent or authorization if the individual's involvement is related to such information. We may also give medical information, including prescription information or information concerning your appointments to friends who are involved in your care only as allowed by Iowa law. We may also give such information to someone who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.
As Required By Law: We will disclose medical information about you when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety: We may disclose medical 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. Any disclosure, however, would only be to someone able to help prevent the threat
To Business Associates: Ivory Lotus Therapy will from time to time hire consultants, known as ''business associates"; who render services to Ivory Lotus Therapy. We may disclose your medical information to such consultants. Business associates are required to maintain and comply with the privacy requirements of state and federal law and keep your medical information confidential Examples of ''business associates" are accounting firms that are hired to perform audits of billing and payment information, and computer software vendors who assist Ivory Lotus Therapy in maintaining and processing medical information
Military and Veterans: lf you are a member of the armed forces, we may release medical Information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
Worker's Compensation: We may release medical information about you for worker's compensation or similar programs, and these program’s benefits for work-related injuries or illnesses.
Public Health Risks: We may disclose medical information about you for public health activities. These activities generally include the following:
to prevent or control disease, injury or disability;
to report reactions to medications or problems with products;
to notify people of recalls of products they may be using;
to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease condition;
to notify the appropriate government authority if we believe a patient has been a victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree to when required or authorized by law.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually. this includes medical and billing records, but does not include psychotherapy notes.
To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing at Ivory Lotus Therapy, 225 NE Dartmoor Drive Suite 300, Waukee, Iowa 50263. 515-650-2454
If you request a copy of the information, we may charge a reasonable fee for the costs of copying. mailing and/or other supplies associated with your request
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Ivory Lotus Therapy will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Request Amendment: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Ivory Lotus Therapy if the information is contained in our designated record set, which usually includes medical and billing records. To request an amendment, your request must be made in writing and submitted to the Privacy Officer. In addition, you must provide a reason that supports your 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. 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 that amendment;
Is not part of the medical information kept by Ivory Lotus Therapy or its affiliates;
Is not part of the information which you would be permitted to inspect and copy; or
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 medical information about you that are not disclosures for treatment, payment and health care operations.
To request this list or accounting of disclosures, you must submit your request in writing to Ivory Lotus Therapy. Your request must state a time period, which may not be longer than six years. Your request will be provided to you on paper. 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 will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions: You have the right to request a restriction or limitation on the mental health treatment or other medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you may request that your spouse or child who is involved in your care not receive certain information about your condition.
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.
To request restrictions, you must make your request in writing to Ivory Lotus Therapy. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosure to your spouse.
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 Ivory Lotus Therapy. We will not ask the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.
To obtain a paper copy of this Notice contact Ivory Lotus Therapy - 225 NE Dartmoor Drive Suite 300, Waukee, Iowa 50263.
COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with Ivory Lotus Therapy or any of its affiliates or with the Secretary of the Department of Health and Human Services. To file a complaint with Ivory Lotus Therapy at 515-650-2454. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION: Other uses and disclosure of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission as set out in an authorization signed by you. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you