Notice of Privacy Practices
Grounded Nutrition Therapy, LLC
2629 W Main Street, Suite 130, Littleton, CO 80120
720.319.8384
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to
protecting health information about you. I create a record of the care and services you receive from me.
I need this record to provide you with quality care. This notice applies to all of the records of your care
generated by this practice. I am required by law to:
Make sure that protected health information (PHI) that identifies you is kept private.
Notify you promptly if a breach occurs that may have compromised the privacy or security of your
information.
Give you this notice of my legal duties and privacy practices with respect to health information.
Follow the terms of the notice that is currently in effect.
I can change the terms of this notice, and such changes will apply to all information I have about
you. The new notice will be available upon request and on my website.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
For Treatment, Payment, or Health Care Operations: When possible, I will request your written or verbal
permission to discuss your care with any other providers. Federal privacy regulations allow health care
providers who have direct treatment relationship with the client to use or disclose the clientʼs PHI
without the patientʼs written authorization, to carry out the health care providerʼs own treatment,
payment, or health care operations. I may also disclose your protected health information for the
treatment activities of a health care provider. This too can be done without your written authorization.
For example, a doctor sends us information about your diagnosis and treatment plan so we can arrange
additional services.

The word “treatment” includes, among other things, the coordination and management of health care
providers with a third party, consultations between health care providers, and referrals of a patient for
health care from one health care provider to another. Please know my goal is to always to provide you
with appropriate and comprehensive care in a respectful and discretionary way.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a
court or administrative order, or in response to a subpoena.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
. Session Notes: I do keep “Session notes” and any use or disclosure of such notes requires your
Authorization unless the use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising associates to help them improve their clinical skills.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with
HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the session
notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
. Marketing Purposes. As a health care provider, I will not use or disclose your PHI for marketing
purposes.
. Sale of PHI. As a health care provider, I will not sell your PHI in the regular course of my business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for
the following reasons:

. When disclosure is required by state or federal law, and the use or disclosure complies with and is
limited to the relevant requirements of such law.
. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or
preventing or reducing a serious threat to anyoneʼs health or safety.
. For health oversight activities, including audits and investigations.
. For judicial and administrative proceedings, including responding to a court or administrative order,
although my preference is to obtain an Authorization from you before doing so.
. For law enforcement purposes or with a law enforcement official.
. To coroners or medical examiners, when such individuals are performing duties authorized by law.
. For research purposes.
. Specialized government functions, such as military, national security, and presidential protective
services
. For workersʼ compensation purposes. Although my preference is to obtain an Authorization from
you, I may provide your PHI in order to comply with workersʼ compensation laws.
. Appointment reminders and health related benefits or services. I may use and disclose your PHI to
contact you to remind you that you have an appointment with me. I may also use and disclose your
PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that
you indicate is involved in your care or the payment for your health care, unless you object in whole or in part.
The opportunity to consent may be obtained retroactively in emergency situations.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not
to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not
required to agree to your request, and I may say “no” if I believe it would affect your health care.
. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to
request restrictions on disclosures of your PHI to health plans for payment or health care
operations purposes if the PHI pertains solely to a health care item or a health care service that you
have paid for out-of-pocket in full.

. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a
specific way (for example, home or office phone) or to send mail to a different address, and I will
agree to all reasonable requests.
. The Right to See and Get Copies of Your PHI. Other than “session notes,” you have the right to get
an electronic or paper copy of your medical record and other information that I have about you. I
will provide you with a copy of your record, or a summary of it, if you agree to receive a summary,
within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for
doing so.
. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of
instances in which I have disclosed your PHI for purposes other than treatment, payment, or health
care operations, or for which you provided me with an Authorization. I will respond to your request
for an accounting of disclosures within 60 days of receiving your request. The list I will give you will
include disclosures made in the last six years unless you request a shorter time. I will provide the
list to you at no charge, but if you make more than one request in the same year, I will charge you a
reasonable cost based fee for each additional request.
. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a
piece of important information is missing from your PHI, you have the right to request that I correct
the existing information or add the missing information. I may say “no” to your request, but I will tell
you why in writing within 60 days of receiving your request.
. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of
this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have
agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
. File a Complaint if You Feel Your Rights are Violated. You can file a complaint with the U.S.
Department of Health and Human Services Office for Civil Rights by sending a letter to 200
Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/ (https://www.hhs.gov/ocr/privacy/hipaa/complaints/)
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on November 1, 2020; Updated on February 21, 2025
Acknowledgement of Receipt of Privacy Notice
By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of
Privacy Practices.