Wellness Boutique Notice of Privacy Practices for Protected Health Information (PHI) 


Wellness Boutique is required by a federal regulation, known as the HIPAA Privacy Rule, to maintain the privacy of your Protected Health Information (PHI) and to provide you with notice of its legal duties and privacy practices. This practice will not use or disclose your PHI except as described in this Notice. The practice is permitted by federal privacy laws to make uses and disclosures of your PHI for purposes of treatment, payment, and health care operations. Protected PHI is the information we create and obtain in providing our services to you. The PHI about you is documented in a medical record and on a computer. Such information may include documenting your symptoms, medical history, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services. Examples of Uses of your PHI for Treatment Purposes are:

1. We will provide a copy of your report to the physician and may provide a copy of the report to another specialist for treatment.

2. During the course of your treatment, Dr. Quaye determines she will need to consult with another physician with special expertise. She will share the information with such specialist and obtain his/her input.

Example of Use of your PHI for Payment Purposes:

We submit requests for payment to your health insurance company. The health insurance company (or other business associate helping us obtain payment) requests PHI from us regarding medical care given. We will provide information to them about you and the care given, which may include copies or excerpts of your medical record which are necessary for payment of your account. For example, a bill sent to your health insurance company may include information that identifies your diagnosis, and the procedures and supplies used.

Example of Use of your PHI for Health Care Operations:

We obtain services from our insurers or other business associates (an individual or entity under contract with us to perform or assist us in a function or activity that necessitates the use or disclosure of PHI) such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical transcription, medical review, legal services, and insurance. We will share PHI about you with our insurers or other business associates as necessary to obtain these services. We require our insurers and other business associates to protect the confidentiality of your PHI.

Your PHI Rights

The health and billing records we maintain are the physical property of the doctorʼs practice. The information in it, however, belongs to you. You have a right to: 

1. Request a restriction on certain uses and disclosures of your PHI by delivering the request in writing to our practice—we are not required to grant the request but we will comply with any request granted;

2. Request not to disclose certain PHI to health plan if the information solely concerns a health care item or service that the patient has paid for in full out-of-pocket (i.e. patient pays in full for a service upon delivery of that service and request that his/her physicians not submit the bill to his/her commercial health plan).

3. Obtain a paper copy of this Notice of Privacy Practices for Protected PHI (“Notice”) by making a request at our practice;

4. Request that you be allowed to inspect and review your medical record and billing record— you may exercise this right by delivering the request in writing to our practice using the form we provide to you upon request;

5. Appeal a denial of access to your protected PHI except in certain circumstances;

6. Request that your medical record be amended to correct incomplete or incorrect information by delivering a written request, including a reason to support it, to our practice using the form we provide to you upon request. (We are not required to make such amendments);

7. File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected PHI;

8. Obtain an accounting of disclosures of your PHI as required to be maintained by law by delivering a written request to our practice using the form we provide to you upon request. An accounting will not include uses and disclosures of information for treatment, payment, or health care operations; disclosures or uses made to you or made at your request; uses or disclosures made pursuant to an authorization signed by you; or to family members or friends or uses relevant to that personʼs involvement in your care or in payment for such care; or uses or disclosures to notify family or others responsible for your care of your location, condition, or your death; we may charge a cost-based fee for more than one accounting in a 12-month period.

9. Request that confidential communication of your PHI be made by alternative means or at an alternative location by delivering the request in writing to our practice using the form we provide to you upon request; and,

10. Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our practice.

If you want to exercise any of the above rights, please contact Borley Quaye, Privacy Officer, 843-639-6012 PO BOX 1763 Hartsville, SC 29551 in person or in writing, during normal business hours. Our Privacy Officer will provide you with assistance on the steps to take to exercise your rights.

Our Responsibilities: 

The practice is required to:

1. Maintain the privacy of your PHI as required by law;

2. Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you (Since we rarely meet the patients for whom we provide diagnostic laboratory services, we make it available in our practice and post it on our website.);

3. Abide by the terms of this Notice;

4. Notify you if we cannot accommodate a requested restriction or request; and

5. Accommodate your reasonable requests regarding methods to communicate health information with you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected PHI we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice,” by visiting our practice and picking up a copy, or by visiting the website.

To Request Information or File a Complaint

If you have questions, would like additional information, want to report a problem regarding the handling of your information, of if you believe your privacy rights have been violated and wish to file a written complaint with our practice, please contact Borley Quaye, Privacy Officer, 843-639-6012 PO BOX 1763 Hartsville, SC 29551. You may also file a complaint by mailing it or emailing it to the Secretary of Health and Human Services.

1. We cannot, and will not, require you to waive your rights under the Privacy Rule including the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the practice.

2. We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.

Other Disclosures and Uses We Can Make Without Your Written Authorization 

Listed below are a number of other ways we are permitted or required to use or disclose your PHI. This list is not exhaustive and every use or disclosure in a category is not listed.

Notification of Family/Friends

Unless you object, we may use or disclose your protected PHI to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your general condition.

Communication with Family/Friends

Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, PHI relevant to that persons involvement in your care or in payment for such care if you do not object or in an emergency.

Disaster Relief

We may use and disclose your PHI to assist in disaster relief efforts.

Deceased Persons & Organ Procurement Organizations

We may disclose your PHI to funeral directors, medical examiners, or coroners consistent with applicable law to allow them to carry out their duties. We may also release PHI about patients to funeral directors as necessary for them to carry out their duties. Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Food and Drug Administration (FDA)

We may disclose to the FDA your PHI relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workersʼ Compensation

If you are seeking compensation through Workersʼ Compensation, we may disclose your PHI to the extent necessary to comply with laws relating to Workersʼ Compensation.

Public Health

As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or

spreading a disease or condition. We may disclose your PHI to public authorities as allowed by law to report abuse, neglect, or domestic violence.


If you are an inmate of a correctional institution or under the custody of a law enforcement Officer, we may disclose to the institution or law enforcement official PHI necessary for your health and the health and safety of other individuals.

Law Enforcement

We may disclose your PHI for law enforcement purposes as required by law, such as when required by a court order; for identification of a victim of a crime if certain protective requirements are met; to report a crime on our premises; to report crime in emergencies; and other appropriate situations permitted by law.

Health Oversight

We may disclose your PHI to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings

We may disclose your PHI in the course of any judicial or administrative proceeding as allowed or required by law or as directed by a proper court order or in response to a subpoena, with your authorization, discovery request or other lawful process if certain specific requirements are met.

Serious Threat

To avert a serious threat to health or safety, we may disclose your PHI consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

For Specialized Governmental Functions

We may disclose your PHI for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Other Uses

Other uses and disclosures of your PHI besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided in this Notice. Sale of your PHI will require specific written authorization from the patient. We may not disclose prior to obtaining the authorization.


We may disclose your PHI to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected PHI.


We do not participate in psychotherapy directly in the office but will comply with HIPPA regulations if it is in the patient records from a previous physician visit.


We will not use your information for marketing purposes.

Effective Date: 10/01/2013