Privacy Policy

Health and Wellness of Texas

Patient Consent for Use and Disclosure of Protected Health Information (PHI)
PCIHIPPA PHI Updated on: February 14, 2024

I hereby give my consent for Health and Wellness of Texas to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by Health and Wellness of Texas describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. Health and Wellness of Texas reserves the right to revise its Notice of Privacy Practices at any time. A Notice of Privacy Practices may be obtained by forwarding a written request to Dr. Jenny Marchuk, NMD.
With this consent, Health and Wellness of Texas may call my home or cellular phone and leave a message on voice mail in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, calls pertaining to my clinical care, including laboratory test results, supplementation, among other information.
With this consent, Health and Wellness of Texas may mail my home or other alternative locations any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”

I have the right to request that Health and Wellness of Texas restrict how the use or disclosure of my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, Health and Wellness of Texas is bound by this agreement.

I may revoke my consent in writing, except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Health and Wellness of Texas may decline to provide treatment to me.