NICOLE WELSH NUTRITION, INC.
NOTICE OF PRIVACY PRACTICES
EFFECTIVE: [February 12, 2026]
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
What is “Medical Information”?
“Medical information” is synonymous with “PHI” for purposes of this Notice of Privacy Practices (“Notice”). PHI means (1) any individually identifiable health information, such as your name, social security number, email address, date of birth, etc., whether written, oral, or recorded in any other manner, that is created or received by a healthcare provider (“me”); and (2) relates to your past, present, or future physical or mental health or condition; healthcare provided to you; or past, present, or future payment for healthcare provided to you.
I AM A NUTRITIONIST WHO IS CURRENTLY COMPLETING SUPERVISED PRACTICE HOURS TOWARD ELIGIBILITY FOR THE CERTIFIED NUTRITION SPECIALIST® (CNS) CREDENTIAL. In my role as a nutritionist, I create and maintain treatment records that contain your PHI. This Notice, among other things, concerns the privacy and confidentiality of those records.
Uses and Disclosures Without Your Authorization - For Treatment, Payment, or Healthcare Operations
Federal law allows me, as someone who has a direct treatment relationship with you, to use or disclose your PHI without written authorization to carry out treatment, payment, or healthcare operations. I may also disclose your PHI to assist another healthcare provider with your treatment.
An Example of Use or Disclosure for Treatment Purposes:
If I consult with another healthcare provider about your condition, I am permitted to use and disclose your PHI, to assist in the treatment of your health condition.
An Example of Use or Disclosure for Payment Purposes:
If your health plan requests a full or partial copy of your health records to determine whether payment is warranted under the terms of your policy or contract, I may use and disclose your PHI.
An Example of Use or Disclosure for Healthcare Operations Purposes:
If your health plan decides to audit my practice to review my competence and my performance, or to detect possible fraud or abuse, your PHI may be used or disclosed solely for those purposes.
PLEASE NOTE: I, or someone in my practice acting with my authority, may contact you without prior written authorization to provide appointment reminders or information about treatment alternatives or other health-related benefits and services.
Other Uses and Disclosures Without Your Authorization:
I may be required or permitted to disclose your PHI without your written authorization in certain circumstances, including when a disclosure is required or permitted:
· By court order.
· By a board, commission, or administrative agency legally authorized to issue investigative subpoenas or resolve disputes.
· By a party to a court proceeding or administrative agency hearing for purposes of satisfying a subpoena, notice to appear, or any other lawful discovery request.
· By an arbitrator or arbitration panel under a subpoena or other lawful discovery request.
· By a lawfully issued search warrant from a governmental law enforcement agency.
· By the patient or the patient’s representative under state or federal law.
· By the California Child Abuse and Neglect Reporting Act, if I have a reasonable suspicion of child abuse or neglect.
· By the California Elder/Dependent Adult Abuse Reporting Law, if I have a reasonable suspicion of elder abuse or dependent adult abuse.
· If you are in a mental or emotional state where you are a danger to yourself or to the person or property of others, and if I determine that disclosure is necessary to prevent the threatened danger.
· To avert a serious, imminent threat of physical violence to be committed by you against a reasonably identifiable victim or victims or against you from a known threat.
· In the event of your death, to the coroner in order to determine the cause of your death.
· To a health oversight agency for authorized oversight activities, including, but not limited to, audits, criminal or civil investigations, or licensure or disciplinary actions.
· For public health purposes, such as infectious disease control or prevention.
· To the Secretary of the U.S. Department of Health and Human Services (“HHS”) to investigate or determine my compliance with federal requirements.
· For research purposes.
· For military and veterans’ activities, such as public benefits distribution.
· For workers’ compensation purposes, e.g., to determine benefits for work-related injuries.
PLEASE NOTE: This list is not exhaustive, but informs you of most circumstances in which disclosures without your written authorization may be made. Other uses and disclosures will generally be made only with your written authorization, even though applicable law may allow additional uses or disclosures without your written authorization.
Uses and Disclosures Requiring Your Authorization:
· Psychotherapy notes, when they are not used to carry out specific treatment, payment, or healthcare operations.
· Marketing purposes (e.g., communication to you encouraging the purchase of a product).
· Sale of PHI.
Uses or disclosures made with your written authorization will be limited to PHI identified “in a specific and meaningful fashion” in the authorization form. You may submit a written revocation of your authorization at any time, except to the extent that I have acted in reliance upon the authorization or if the authorization was obtained as a condition of obtaining your insurance coverage. IF CALIFORNIA LAW PROTECTS YOUR CONFIDENTIALITY OR PRIVACY MORE THAN FEDERAL LAW, OR IF CALIFORNIA LAW GIVES YOU GREATER RIGHTS WITH RESPECT TO ACCESS TO YOUR RECORDS, I WILL ABIDE BY CALIFORNIA LAW.
In general, uses or disclosures of your PHI without your authorization will be limited to the minimum necessary to accomplish the intended purpose of the use or disclosure. When I request your PHI from another healthcare provider, health plan, or healthcare clearinghouse, I will try to limit the request to the minimum necessary to accomplish the intended purpose of the request.
Your Rights Regarding PHI
· To request restrictions on certain uses and disclosures of your PHI, such as those necessary to carry out treatment, payment, or healthcare operations. I am not required to agree to your requested restriction, unless the disclosure is for payment or healthcare operations purposes and not otherwise required by law, and the PHI relates solely to a healthcare item or service for which you have paid in full. If I do agree, I will maintain a written record of the agreed-upon restriction.
· To receive confidential communications of PHI from me by alternative means or at alternative locations.
· To make a written request to inspect and receive a copy of your PHI, which I am permitted to deny for specified reasons. For instance, you may not access my “nutrition counseling notes.” My counseling notes document or analyze the contents of our conversations during our private counseling sessions and are separate from the rest of your medical record. Counseling notes do not include prescription monitoring, counseling session start and stop times, types and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, and progress to date.
· To amend PHI in my records by submitting a written request that provides a reason to support the requested amendment, which I am permitted to deny for specified reasons. YOU ALSO HAVE THE RIGHT, SUBJECT TO LIMITATIONS, TO PROVIDE ME WITH A WRITTEN ADDENDUM WITH RESPECT TO ANY ITEM OR STATEMENT IN YOUR RECORDS THAT YOU BELIEVE TO BE INCORRECT OR INCOMPLETE AND TO HAVE THE ADDENDUM BECOME A PART OF YOUR RECORD.
· To receive an accounting of disclosures of PHI made by me in the six years prior to the date of request, which I am permitted to deny for specified reasons. For instance, I do not have to account for disclosures made to carry out my own treatment, payment or healthcare operations. I also do not have to account for disclosures of PHI that are made with your written authorization as you have a right to receive a copy of any signed authorization.
· To obtain a paper copy of this Notice from me upon request.
PLEASE NOTE: To avoid confusion or misunderstanding, I ask that if you wish to exercise any of your rights described above, that you submit a written request. If you wish to learn more detailed information about any of your rights, or their limitations, please let me know.
My Duties
I am required by law to maintain the privacy and confidentiality of your PHI. This Notice is intended to let you know my legal duties, your rights, and my privacy practices with respect to such information. I am required to abide by the terms of the Notice currently in effect. I reserve the right to change the terms of this Notice and/or my privacy practices and to make the changes effective for all PHI that I maintain, even if it was created or received prior to the effective date of the Notice revision. If I make a revision to this Notice, I will make the Notice available at my office upon request on or after the effective date of the revision and I will post the revised Notice in a clear and prominent location.
I have a duty to develop, implement, and adopt privacy policies and procedures (“P&Ps”) and have done so. I am responsible for assuring that these P&Ps are followed not only by me, but by any current or future practice employees. I have trained or will train my employees to understand my P&Ps. In general, patient records, and information about patients, are treated as confidential and are not released without a patient’s written authorization, except as indicated in this Notice or otherwise permitted by law. Patient records are securely stored and may only be accessed by employees with a need to do so. Should there be an unauthorized acquisition, use, access, or disclosure of PHI in an unprotected form, i.e., unencrypted data, I will notify all impacted patients in accordance with applicable law.
You may submit a complaint if you believe your privacy rights may have been violated by me or any of my employees. You may file a written complaint with me specifying the manner of the alleged violation, the approximate date of such occurrence, and any details helpful to investigate the incident, or contact me at [3107179300]. I will not retaliate against you for filing a complaint. You may also file a written complaint with the HHS Secretary and send it to U.S. Department of Health and Human Services, 50 United Nations Plaza, Room 431, San Francisco, CA 94102.
Inability To Obtain Acknowledgment of Receipt of Notice of Privacy Practices
I made good faith attempts to obtain my patient’s acknowledgment of his or her receipt of my Notice of Privacy Practices, including:
However, because of: _________________________, I was unable to obtain my patient’s acknowledgment.
Acknowledgment of Receipt of Notice
By signing this form, you acknowledge receipt of the Notice, which provides information about how I may use and disclose your PHI. I encourage you to read it in full. My Notice is subject to change. If changes are made, you will receive a copy of the revised Notice. If you have any questions about the Notice or its contents, please contact me through one of the following channels:
Nicole Welsh
8605 Santa Monica Blvd.
PMB 759523
West Hollywood, CA 90069-4109
3107179300