Notice of Privacy Practice
We are REBALANCE Medical Aesthetics (“Company”,”we”,”us”,”our”), a company registered in Tennessee, United States, at 7305 Jarnigan Road Suite 105, Chattanooga, TN 37421.
NOTICE OF PRIVACY PRACTICES
Effective Date 09 /15 /2025
This Notice of Privacy Practices (the “Notice”) describes how medical information about you, as the patient of the REBALANCE Medical Aesthetics, may be used and disclosed, and how you can get access to this information. This Notice is required by the privacy regulations created under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Please read it carefully.
***
PRIMARY USES AND DISCLOSURES
This section describes the primary ways we use and/or share your health information. We may use and disclose your health information about you in the following ways:
For Your Treatment. We can use your health information and share it with other health care professionals who are treating you including, but not limited to: doctors, nurses, technicians, health students, or other personnel who are involved in your medical treatment and care. These other healthcare professionals may work at our Practice, at a hospital if you are hospitalized under our supervision, at another doctor’s office, lab, pharmacy, or other health care provider that we may refer you to for consultation or treatment.
For Our Practice Operations. We can use and share your health information to run our Practice, manage and improve your care, and contact you when necessary. We may use your health information to review our provision of treatments and services and to evaluate the performance of our staff. We may combine health information about many patients, including you, to decide what additional services we should offer, what additional services may be needed, whether new services and treatments are effective, or to compare ourselves to other practices to see where we can make improvements. In some cases, we may remove information that identifies you from this set of health information so that others can use it for purposes of studying and analyzing health care metrics and information.
For Payment Purposes. We can use and share your health information so that the treatment and services you receive from us can be billed to and payment collected from you, an insurance company, health plan, or other third party. We may need to give your health plan information about your visit so they can pay or reimburse us for the visit. We may also tell your health plan or third-party payer about a treatment you are planning to receive in advance of your receiving such treatment in order to determine if your plan will cover the treatment.
OTHER PERMITTED USES AND DISCLOSURES
We are also allowed, or may be required to share your information, in other ways, which include the following:
For Public Health Purposes. We can share your health information in certain public health situations such as:
To prevent disease
To assist with product recalls
To report adverse reactions to treatments or medications
To prevent or reduce a serious threat to anyone’s health or safety
As Required by Law & Legal Proceedings. We will share your health information if local, state, or federal law requires it, including, without limitation if the Department of Health and Human Services requests it to ensure we are complying with federal privacy laws. We may also disclose your health information when we are legally required to do so for any judicial or administrative proceeding, in response to an order of a court or administrative tribunal, or in certain conditions in response to a subpoena, discovery request or other lawful purposes.
For Purposes of Health Oversight. We may disclose your health information to health oversight agencies for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information may include government agencies that oversee the health care system, government benefit programs, other government regulatory programs.
In Relation to Communicable Diseases. We may disclose your health information, if authorized by law, to a person who may have been exposed to a communicable disease or otherwise may be at risk of contracting or spreading the disease or condition.
In Cases of Abuse or Neglect. We may disclose your health information to a public health authority that is authorized by law to receive reports of child abuse, domestic violence, or neglect. In addition, we may disclose your health information if we believe that you have been a victim of abuse, domestic violence, or neglect to the governmental entity or agency authorized to receive such information.
As Required by the Food and Drug Administration. We may disclose your health information to a person or company required by the Food and Drug Administration (“FDA”) for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, without limitation, reporting of product defects or problems, adverse reactions and/or events, biologic product deviations, product tracking purposes, to aid in product recalls, to aid in making repairs or replacements, or for conducting post marketing surveillance, as such may be required.
For Research Purposes. We can use or share your information for health research purposes.
In Response to Organ and Tissue Donation Requests. We can share your health information with organ procurement organizations.
To Work with a Medical Examiner or Funeral Director. We can share your health information with a coroner, medical examiner, or funeral director in the event of your death.
To Address Workers’ Compensation, Law Enforcement, and Other Government Requests. We can use or share your health information:
For workers’ compensation claims
For law enforcement purposes or in working with a law enforcement official
For special government functions such as military, national security, and presidential protective services
With health oversight agencies for activities as authorized by law
In Relation to Military Personnel and Veterans. If you are a member of the armed forces or separated/discharged from military services, we may release your health information as required by military command authorities or the Department of Veterans Affairs as may be applicable. We may also release your health information about foreign military personnel to the appropriate foreign military authorities.
YOUR RIGHTS
When it comes to your health information, you have certain rights. This section explains your rights. You have the right to:
Get a copy of this Notice. You can ask for a paper copy of this notice at any time and one will be provided to you, even if you have agreed to receive the notice electronically.
Get an electronic or paper copy of your medical record. You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. To do this, you can contact our Privacy Officer as listed at the end of this Notice. We will provide a copy or a summary of your health information, usually within 30 days from the date of your request. We may charge you a reasonable, cost-based fee.
Ask us to correct your medical record. You can ask us to correct your health information if you think it is incorrect or incomplete. You can submit this request to our Privacy Officer. We may deny your request, but we will tell you the reason for the denial by sending you a written letter within 60 days.
Request confidential communications. You can ask us to contact you in a specific way (for example, at a home or office phone) or to send mail to a different address. We will comply with all reasonable requests.
Ask us to limit what we use or share. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may deny your request if we determine that it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurance company. We will comply with such a request unless a law requires us to share that information.
Get a list of those with whom we’ve shared information. You can ask for a list of all the times we have shared your health information over the past six years, which will include who we shared it with and why we shared it. In response, we will include all disclosures made except for those about treatment, payment, health care operations, and disclosures requested by you. We will provide this list to you for free once per year, but any additional requests will be charged at a reasonable, cost-based fee.
Choose someone to act for you. If you have given someone medical power of attorney to act on your behalf or if someone has been appointed as your legal guardian, that person can exercise your rights and make choices about your health information. We will check the validity of such authorization or appointment and will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated. You can file a complaint if you feel we have violated your rights regarding your health information by contacting our Privacy Officer. You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf
We will not retaliate against you for filing a complaint.
YOUR CHOICES
With respect to some of your health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, please contact the Privacy Officer. You can tell us what you want us to do, and we will follow your instructions.
You have the right and choice to tell us to:
Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory
If the event you are not able to tell us your preference (for example, you are unconscious or incapacitated), we may share your health information if we believe it is in your best interest. We may also share your health information when needed to lessen a serious and imminent threat to health or safety.
We will never share your information unless you give us your prior written consent in the following cases:
Marketing purposes
Sale of your health information
Most sharing of psychotherapy notes
With respect to fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again.
OUR RESPONSIBILITIES
This section describes our responsibilities with respect to your health information.
We are required by law to maintain the privacy and security of your protected health information.
We will not use or share your health information other than as described in this Notice, unless you authorize us to do so in writing. If you authorize disclosures of your health information outside of those described in this Notice, then you may change your mind at any time by informing us in writing by contacting the Privacy Officer.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your health information.
We must follow the duties and privacy practices described in this Notice.
We must give you a copy of this Notice.
We can change the terms of this Notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website (as applicable).
PRIVACY OFFICER
If you have questions, concerns, complaints, or other requests, you should contact our Privacy Officer as follows:
Name: Krystal “Cami” Killom, FNP
Address: 7305 Jarnigan Road Suite 105, Chattanooga, TN 37421
Email: camikillom@byrebalance.com
Phone: 423-602-5220
