HIPPA
HIPAA Notice, Acknowledgment of Receipt & Communication Consent
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.
This document applies exclusively to VIP Regen Med LLC d/b/a VIPrivate Care Longevity & Anti-Aging. Prime IV Hydration & Wellness, operated at the same address by Health & Longevity LLC, is a separate non-medical wellness business with its own privacy practices, financial policies, systems, and forms. Nothing in this document applies to Prime IV services, and no information collected under this document is shared with Prime IV except as you separately authorize in writing.
Related Documents
VIPC-ADM-001 — Privacy Policy. Covers information beyond protected health information, including website and payment data.
VIPC-ADM-003 — Financial Agreement & Policies. Governs payment, cancellation, and refunds.
Each document is signed separately. Signing one does not commit you to another.
What Signing This Document Means
Part A is the notice itself. Part B is your acknowledgment that you received it. Acknowledging receipt is not consent to treatment, not consent to marketing, and not a waiver of any right.
Part C is a separate, optional communication consent with its own signature. You may decline all of it and still receive every service the Practice offers, on the same terms and at the same price.
Part A — Notice of Privacy Practices
Our Legal Duty
We are required by applicable federal and state law, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act, to maintain the privacy of your protected health information (PHI), to give you this notice of our privacy practices, our legal duties, and your rights concerning your PHI, and to follow the practices described in this notice while it is in effect.
Uses and Disclosures Without Your Written Authorization
Treatment — to provide, coordinate, or manage your health care and related services, including consultation between providers involved in your care.
Payment — to obtain payment for services, including billing, claims management, and collection activity.
Health Care Operations — for quality assessment, staff training, licensing, accreditation, and business planning necessary to run the Practice.
As Required by Law — when federal, state, or local law requires disclosure, including reporting to public health authorities, the FDA, and law enforcement under specified conditions.
Public Health Activities — to report disease, injury, and vital events, and to support public health surveillance and investigation.
Health Oversight — for audits, investigations, inspections, and licensure activities by health oversight agencies.
Judicial and Administrative Proceedings — in response to a court order, subpoena, or other lawful process.
Serious Threat to Health or Safety — to prevent or lessen a serious and imminent threat to you or to the public.
Uses and Disclosures That Require Your Written Authorization
The following always require your separate written authorization, which you may revoke at any time in writing:
Most uses and disclosures for marketing purposes.
Any sale of your protected health information. We do not sell PHI.
Most uses and disclosures of psychotherapy notes, if any exist.
Use of your clinical photographs, video, or case history in any promotional or educational material. This is offered on a separate release form, and declining it never affects your care.
Your Rights
Inspect and copy — you may inspect and obtain a copy of your PHI, in electronic form where we maintain it electronically. We may charge a reasonable, cost-based fee.
Request amendment — you may request an amendment if you believe your PHI is incorrect or incomplete. We may deny the request in circumstances the law specifies, and you may file a statement of disagreement.
Accounting of disclosures — you may request a list of disclosures we have made other than for treatment, payment, or operations.
Request restrictions — you may request restrictions on certain uses and disclosures. We are not required to agree, except that we must honor a request to restrict disclosure to a health plan where you have paid for the service in full out of pocket.
Confidential communications — you may ask that we contact you at a particular telephone number or address.
Paper copy — you may receive a paper copy of this notice on request, even if you agreed to receive it electronically.
Breach notification — you have the right to be notified of a breach of your unsecured PHI.
File a complaint — you may complain to our Privacy Officer or to the Secretary of the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.
Changes to This Notice
We reserve the right to change the terms of this notice and to make the revised notice effective for all PHI we maintain. Any revised notice will be posted in our office and on our website.
Contact
Privacy Officer: ______________________________ | 201.730.4783 | concierge@viprivatecarelongevity.com | 295 W Grand Ave, Unit C, Montvale, NJ 07645
To complain to HHS: Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, DC 20201 • www.hhs.gov/ocr
Parts B and C (signature forms — intake packet, not website)
Part B — Acknowledgment of Receipt
I acknowledge that I have received and had the opportunity to review the Notice of Privacy Practices of VIPrivate Care Longevity & Anti-Aging (VIP Regen Med LLC). I understand that this acknowledgment is not consent to treatment, is not consent to marketing, and does not waive any right.
Patient Name (Print) | Date of Birth
Patient Signature | Date
Parent / Legal Guardian or Personal Representative (if applicable) | Relationship
For Office Use Only
☐ Patient received a copy of this Notice.
☐ Patient declined to sign acknowledgment. Good-faith effort documented below as required by 45 CFR 164.520(c)(2)(ii).
Staff initials: ________ Date: ____________ Notes: ______________________________________________
Part C — Communication Consent (Optional)
This Part Is Optional
Your care does not depend on this part. You may decline every box below and still receive every service the Practice offers, on the same terms and at the same price.
We will always be able to contact you about your own appointments and care. This part is only about how, and about whether we may send you promotional messages.
Appointment and Care Communications
Please indicate how you prefer we reach you about your appointments, results, and follow-up care:
☐ Text message (SMS)
☐ Telephone call
☐ Postal mail
Preferred number or address for confidential communications, if different from the intake form: ______________________________________________
Marketing and Promotional Communications
Separately from the above, you may consent to receive promotional messages about services, events, memberships, and offers. This is a distinct consent under the federal
Telephone Consumer Protection Act and applicable New Jersey law.
☐ YES — I consent to receive marketing text messages (SMS), which may be sent using automated technology, at the mobile number I provide.
☐ YES — I consent to receive marketing emails.
☐ YES — I consent to receive marketing telephone calls, which may be prerecorded or use automated technology.
☐ NO — I decline all marketing communications.
Message and data rates may apply. Message frequency varies. Reply STOP to any marketing text to opt out, or HELP for help. Use the unsubscribe link in any marketing email, or contact the office. Consent to marketing is not a condition of receiving any service, and is not required to purchase anything. You may revoke this consent at any time by notifying the office; revocation does not apply to messages already in transmission.
Mobile number for text messages: ______________________________ Email: ______________________________
Signature (Communication Consent — separate from Part B) | Date