We take pride in the appropriate reservation of your procedural dates and scheduled time. Our priority is to schedule procedures that can be attended to with the utmost care. Our office scheduling policy is very time sensitive due to the constraints of the procedure. Therefore, please understand the importance of our Cancellation Policy which entails the following:

If you need to cancel or adjust your appointment date/time, you must notify our office no less than 48 hours in advance of the appointment. A card is required to be saved to each client’s file in accordance with our cancellation and no-show policies. Failure to notify our office about canceling or rescheduling an appointment will result in a charge of $75.

We understand that unexpected life factors can arise and cause you to be late to your scheduled appointment time. For this reason, we allow a 10 minute grace period after your scheduled appointment. This grace period is intended to be used as needed, this does not mean that you can regularly be late to your appointments. If you expect to be late, please call our office to communicate this information.

After 10 minutes, your appointment will be considered as canceled and your card on file will be charged.

Understanding Your Health Record/Information

This notice describes the practices of Benesque Wellness MedSpa by Valeri L Roth, DO and its staff (collectively, "Benesque"), and that of any physician or provider with staff privileges with respect to your protected health information created while you are a patient at Benesque. Benesque, physicians with staff privileges, and personnel authorized to have access to your medical chart are subject to this notice. In addition, Benesque and physicians with staff privileges may share medical information with each other for treatment, payment, or health care operations described in this notice.

We create a record of the care and services you receive at Benesque. We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. This notice applies to all the records of your care at Benesque.

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.

Your Health Information Rights

Although your health record is the physical property of Benesque, the information belongs to you. You have the right to:

● Inspect and request a paper or electronic copy of your health record as provided by law;

● Request that we amend your health record as provided by law. We will notify you if we are unable to grant your request to amend your health record;

● Request communication of your health information by alternative means or at alternative locations. We will accommodate reasonable requests.

● Request a restriction on certain uses and disclosures of your information for treatment, payment, health care operations, and as to disclosures permitted to persons, including family members involved with your care and as provided by law. However, we are not required by law to agree to a requested restriction, unless the request relates to a restriction on disclosures to your health insurer regarding health care items or services for which you have paid out-of-pocket and in full ;

● Obtain an accounting of disclosures of your health information as provided by law;

● Obtain a paper copy of this Notice of Information practices; and

● Choose someone to act for you if you have given someone medical power of attorney or if someone is your legal guardian. We will verify the person’s authority before we take action.

● You may exercise your rights set forth in this notice by providing a written request to Benesque.

Our Responsibilities

In addition to the responsibilities set forth above, we are also required to:

● Maintain the privacy of your health information;

● Subject to certain exceptions under the law, provide notice of any unauthorized acquisition, access, use, or disclosure of your protected health information to the extent it was not otherwise secured;

● Provide you with a notice as to our legal duties and privacy practices with respect to information we maintain about you;

● Abide by the terms of this notice; and

● Notify you if we are unable to agree to a requested restriction on certain uses and disclosures.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain, including information created or received before the change. Should our information practices change, we are not required to notify you, but we will have the revised notice available upon your request at Benesque.

Uses and Disclosures of Medical Information That Do Not Require Your Authorization

The following categories describe different ways that we may use and disclose medical information without your authorization. For each category of uses or disclosures, we will explain what we mean, but not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information without your authorization should fall within one of the categories.

We will use your health information for treatment.

• For example: We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. We may share medical information about you in order to coordinate different treatments, such as prescriptions, lab work, and X-rays . We may also provide your physician or a subsequent health-care provider with copies of various reports to assist in treating you once you are discharged from care at Benesque.

We will use your health information for payment.

• For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

We will use your health information for regular health care operations.

• For example: We may use the information in your health record to assess the care and outcome in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the health care and services we provide.

We will use and disclose your health information as otherwise allowed by law. Below are some examples of those uses and disclosures:

• Business associates: There are some services provided in our organization through agreements with business associates. Examples include answering services and copy services. However, to protect your health information, we require business associates to appropriately safeguard your information.

• Notification: Unless you object, we may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care about your location and general condition.

• Individuals involved in your care: Unless you object, we may disclose to a family member, other relative, a close personal friend, or other person you identify the health information that is directly relevant to that person's involvement in your healthcare or payment for your healthcare. If you are not able to agree or object to such disclosure, we may disclose the information as necessary if we determine it is in your best interest, in our professional judgment.

• Disaster relief: We may use or disclose your health information to public or private disaster relief organizations to coordinate your care or to notify your family or friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to these disclosures when practical.

• Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to protect the privacy of your health

• Communications regarding treatment alternatives and appointment reminders: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

• Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, medications, devices, supplements, product, and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacement.

• Worker's compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs established by law.

• Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

• Abuse, neglect, or domestic violence: As required by law, we may disclose health information to a governmental authority authorized by law to receive reports of abuse, neglect, or domestic violence.

• Judicial, administrative, and law enforcement purposes: Consistent with applicable law, we may disclose health information about you for judicial, administrative, and law enforcement purposes.

• Health oversight activities: We may disclose health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure.

• Threats to health or safety: We may use or disclose health information as allowed by law if we believe in good faith that it is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, or for law enforcement authorities to identify or apprehend an individual involved in a crime.

• Special government functions: We may disclose health information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law, or for protective services to the President of the United States or certain other government officials. If you are a member of the military, we may disclose health information to military authorities under some circumstances. If you are an inmate of a jail, prison, or other correctional facility or in the custody of law enforcement personnel, we may disclose health information necessary for your health and the health and safety of others.

• Required or allowed by law: We will disclose medical information about you when required or allowed to do so by federal, state, or local law.

• Electronic Health Information Exchange: We use a third party to maintain our electronic medical records (“EMR”) and store electronic health information about you in the EMR. We monitor who can view your EMR and limit access to the personnel with an actual need to access your information

When We Need Your Written Authorization

We will not use or disclose your health information without your written authorization, except as described in this notice. Additional uses that might require your additional written authorization are not common, but an example would be uses and disclosures for marketing purposes.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact Benesque at the number provided by our location - (724) 414-3380.

If you believe your privacy rights have been violated, you can send a complaint to the office manager of Benesque at the address provided at office@benesquewellness.com or to the Secretary of Health and Human Services Office of Civil Rights by sending a letter to 200 Independence Ave., S.W., Washington, D.C. 20201; calling (877) 696-6775; or visiting www.hhs.gov.ocr/privacy/hipaa/complains/.

There will be no retaliation against you for filing a complaint.

This Notice of Privacy Practices is effective as of 12/25

We may change our policies and this notice at any time, and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice at the office.

Special Considerations for SUD Record Management: If we receive SUD (substance use disorder) records as the result of a disclosure authorized by you, we are permitted to use and disclose those records for treatment, payment, and/or operations (TPO) purposes in accordance with HIPAA regulations unless you revoke the authorization in writing.  We may disclose those records to public health authorities without your consent, but only if those records have been fully de-identified according to HIPAA regulations.  We will not release those records or your testimony regarding those records for matters of criminal, administrative, legislative, or civil proceedings against you by a local, state, or federal authority unless we receive a court order or a separate and specific patient consent from you.  You may request an accounting of all TPO disclosures of SUD records made electronically for up to three years prior to the date of the request.  We will not use or disclose your SUD records to fundraise for our own benefit.