Effective Date: November 1, 2024
1. Our Privacy Commitment
This notice describes how your Protected Health Information (PHI) may be used or disclosed by Revive Active and Aesthetic PLLC (“Revive”) and explains your rights regarding that information. Please review carefully.
2. How We May Use and Disclose PHI
Revive may use and disclose your PHI for the following purposes:
Treatment – e.g., sharing information with practitioners to coordinate care.
Payment – e.g., submitting PHI to insurers or billing services.
Healthcare Operations – e.g., quality improvement and training.
We may also use/disclose PHI without your authorization for:
- Public health issues (e.g., reporting diseases)
- Law enforcement requests (e.g., subpoenas)
- Abuse or neglect reporting
- Healthcare oversight activities
- Serious threat responses
All other uses (e.g., marketing outside of appointment reminders) will require your written authorization. You may revoke the authorization at any time.
3. Your Rights Regarding PHI
You have the right to:
- Request restrictions on certain uses/disclosures (Revive does not have to agree)
- Receive confidential communications (e.g., alternate delivery methods or locations)
- Inspect and copy your PHI
- Amend your PHI if incorrect or incomplete
- Receive an accounting of disclosures
- Obtain a paper copy of this Notice
- Receive breach notifications as required by law
4. Our Legal Duties
We are required by law to:
- Maintain the privacy and security of your PHI
- Provide this Notice and abide by its terms
- Notify you of any PHI breach
- Inform you of any material changes to this Notice
5. For More Information or to File a Complaint
- For questions or more info, contact:
Privacy Officer: Dr. Michael Harington, MD
Phone: (980) 415‑4442 | Email: support@reviveactiveandaesthetic.com
Address: 128 E Park Street, Charlotte, NC 28203 - No retaliation for filing a complaint
- You may also file a complaint with:
U.S. Department of Health and Human Services Office for Civil Rights
6. Acknowledgement of Receipt
We will make reasonable efforts to obtain your written (or electronic) acknowledgment that you received this Notice.
7. Changes to This Notice
We reserve the right to update this Notice. The revised version will be posted on-site and online. A copy will be available upon request.
8. Contact & Additional Rights
- You have the right to request a copy of PHI, ask for restrictions, or amend your records.
- You may also receive an accounting of disclosures
- You will not face retaliation for exercising any rights listed here.
Revive Active and Aesthetic PLLC
128 E Park Street, Charlotte, NC 28203
(980) 415‑4442 • support@reviveactiveandaesthetic.com
