Privacy Policy

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Understanding Your Health Record/Information

This notice describes the practices of Mint Aesthetics + Wellness and its staff, as well as any physician or provider with staff privileges, with respect to your protected health information created while you are a patient at Mint. Mint, physicians with staff privileges, and personnel authorized to have access to your medical chart are subject to this notice. Mint 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 Mint. We understand that medical information about you and your health is personal, and we are committed to protecting it. This notice applies to all the records of your care at Mint.

This notice tells you about the ways we may use and disclose medical information about you. It also describes 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 Mint, the information belongs to you. You have the right to:

Request a restriction on certain uses and disclosures of your information for treatment, payment, and health care operations, and as to disclosures permitted to persons (including family members) involved with your care and as provided by law. 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 a paper copy of this notice of information practices.
Inspect and request a 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.
Obtain an accounting of disclosures of your health information as provided by law.
Request communication of your health information by alternative means or at alternative locations. We will accommodate reasonable requests.

To exercise your rights set forth in this notice, please submit a written request to:

Mint Aesthetics + Wellness
5283 Competition Drive
Bettendorf, IA 52722

Our Responsibilities

In addition to the responsibilities set forth above, we are 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 of our legal duties and privacy practices with respect to information we maintain about you
Abide by the terms of this notice
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. If our information practices change, we are not required to notify you, but we will have the revised notice available upon request at Mint.

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

The following categories describe different ways we may use and disclose medical information without your authorization. Not every use or disclosure in a category will be listed, but all permitted uses and disclosures should fall within one of the categories below.

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 your care. We may share medical information about you 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 Mint.

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 helps us 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.

Examples include:

Business associates: Some services are provided through agreements with business associates, such as answering services and copy services. 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, a 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 health information directly relevant to a family member, relative, close personal friend, or another person you identify as involved in your care or payment for your care. If you are unable to agree or object, 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 when practical.
Research: We may disclose information to researchers when their research has been approved by an institutional review board with 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.
Food and Drug Administration (FDA): We may disclose to the FDA health information related to adverse events involving food, medications, devices, supplements, products, and product defects, or post-marketing surveillance information for product recalls, repairs, or replacement.
Worker's compensation: We may disclose health information as authorized by and necessary to comply with laws relating to worker's compensation or 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 representative 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 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, counterintelligence, 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, we may disclose health information necessary to maintain 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: Mint uses a third party to maintain our electronic medical records (EMR). Mint stores electronic health information about you in the EMR and monitors who can view your record.

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 circumstances requiring written authorization are not common, but one example would be uses and disclosures for marketing purposes.

For More Information or to Report a Problem

If you have questions or would like additional information, you may contact Mint at 563-800-MINT.

If you believe your privacy rights have been violated, you may send a complaint to the Director of Mint at:

Mint Aesthetics + Wellness
5283 Competition Drive
Bettendorf, IA 52722

You may also send a complaint to the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

This notice is effective as of: November 1, 2024.

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

Notice of Privacy Practices Acknowledgement

I, the undersigned, understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan, and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly
Obtain payment from third-party payers
Conduct normal health care operations, such as quality assessments and physician certifications

I acknowledge that I have been provided the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that Mint Aesthetics + Wellness has the right to change its Notice of Privacy Practices from time to time, and that I may contact Mint at any time at the address above to obtain a current copy.

I understand that I may request in writing that Mint restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand that Mint is not required to agree to my requested restrictions, but if they do agree, they are bound to abide by such restrictions.

Release of Medical Records

By initialing below, I acknowledge that my medical information and records will be released to Mint. I further acknowledge that my medical information and records will be released from Mint to my primary care provider, referring or consulting providers, and my insurance company to process insurance claims.

Initials: _______________

Authorized Individuals

I also allow release of my medical information to the following individuals (e.g., family, caregivers):

Name: ____________________________
Relationship: ____________________________

Patient Signature

Printed Patient Name: ____________________________
Date: ____________________________
Signature of Patient: ____________________________

Mint Representative

Practice Representative Name: ____________________________
Signature of Practice Representative / Witness: ____________________________