HIPAA Notice of Privacy Practices

Health by Design Functional Medicine, Danielle Pichette, DC

Dr. Danielle Pichette, DC, FMACP

5205 Stilesboro Rd. NW, Suite 205, Kennesaw, Ga, 30152

678-404-9950 – [email protected]

THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT

YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS

INFORMATION. PLEASE REVIEW IT CAREFULLY.

In the course of your care as a patient or client with any practitioner at Health by Design Functional Medicine,

we may use or disclose personal and health-related information about you in the following ways:

-Your personal health information, including your clinical records, may be disclosed to another

health care provider or hospital if it is necessary to refer you for further diagnosis, assessment

or treatment.

-Your health care records, as well as your billing records, may be disclosed to another party,

such as an insurance carrier, an HMO, a PPO, or your employer (if they are or may be

responsible for the payment of your services.)

-Your name, address, phone number, and your health care records may be used to contact you

regarding appointment reminders, to provide information about alternatives to your present care,

or to provide other health-related information that may be of interest to you.

-We may also provide treatment in an “open” or “group adjusting” or "group nutrition" or

"group coaching" environment where other patients may be seen and advised at the same time

in close proximity to you.

This situation would necessitate the discussion of your health, subjective symptoms/treatment, etc.

in the presence of other patients.

You may always choose to exclusively participate in private appointments.

**Please see your Membership Agreement for details about our optional group “Open Office Hours”**

You have a right to confidential communications and to request restrictions relative to such

contacts. You also have the right to be contacted by alternative means or at alternative

locations. Such requests must be made to us in writing. Such requests are not automatic and

require the agreement of this office.

If you are not at home to receive an appointment reminder, a message may be left on your

answering machine or with a person in your household.

Further, you have the right to inspect or obtain a copy of the information we will use for these

purposes. You also have the right to refuse to provide authorization for this office to contact you

regarding these matters. If you do not provide us with this authorization it will not affect the care

provided to you or the reimbursement avenues associated with your care.Under federal law, we are

also permitted or required to use or disclose your health information

without your consent or authorization in the following circumstances:

-If we are providing health care services to you based on the orders of another health care

provider.

-If we provide health care services to you in an emergency.

-If we are required by law to provide care to you and we are unable to obtain your consent after

attempting to do so.

-If there are substantial barriers to communicating with you, but in our professional judgment we

believe that you intend for us to provide care.

-If we are ordered by the courts or another appropriate agency.

You have a right to receive an accounting of any such disclosures made by this office. Any use

or disclosure of your protected health information, other than as described in the examples

outlined above, will only be made upon your written authorization. We normally provide

information about your health care to you at the time you receive chiropractic care, bodywork,

health coaching, functional medicine, nutritional advice, etc from us. We may also mail, email or

text information to you regarding your health care or about the status of your account. If you

would like to receive this information at an address other than your home or, if you would like

the information in a different form, please advise us in writing as to your preferences. We use a

HIPAA compliant EHR system and email but please keep in mind there are inherent risks in

electronic communication. If you would prefer to not utilize email as a form of communication

please inform Body Love Cafe in writing and please do not email the office. Sending an email to

[email protected] and asking questions pertaining to health or your personal

information will be presumed as you granting permission to communicate via email along with

this signed HIPAA form.

You have the right to inspect and/or copy your health information for seven years from the date

that the record was created for as long as the information remains in our files. In addition, you

have the right to request an amendment to your health information. As per allowance by HIPAA

recommendations & as a non-covered entity, the charge will be 25 cents per page.

Requests to inspect, copy or amend your health-related information should be provided to us in

writing.

We make every effort to follow the state and federal recommendations to maintain the privacy of

your patient file and the health protected health information therein.

We also make every effort to follow the state and federal recommendations to provide you with

this notice of our privacy practices with respect to your health information. We make every effort

to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice, we will notify you in writing as soon as possible following the changes. Any

change in our privacy notice will apply for all of your health information in our files.

If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our

privacy activities you should direct your complaint to: Dr. Danielle Pichette, Wellness Director, 678-404-9950.

You also have the right to lodge a complaint with the Secretary of the Department of Health and

Human Services at 200 Independence Ave, S.W. Washington D.C. 20201. If you choose to

lodge a complaint with this office or with the Secretary your care will continue, and you will not be

disadvantaged by this office or our staff in any manner whatsoever.

This notice is effective (updated) as of August 15, 2026. This notice and any alterations or

amendments made hereto will expire seven years after the date upon which the record was

created.

All current updates to our Privacy Policy will be immediately applicable to you and all previous

signers and posted on the Health by Design Functional Medicine website and in our Practice Better software. You may view

them there or request an updated copy emailed