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Upcoming Appointment

Please fill out the intake form at least 6 hours prior to your appointment.

Lactation Intake Form

Infant Instincts Privacy Practices and HIPPA

By signing the intake form under NOTICE OF PRIVACY PRACTICES AND HIPPA you are acknowledging that you have read all information below. 

Infant Instincts 


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 Each time you visit a hospital, physician, dentist, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information often referred to as your health or medical record, serves as a basis for planning your care and treatment and serves as a means of communication among the many health professionals who contribute to your care. Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and helps you make more informed decisions when authorizing disclosure to others.

YOUR HEALTH INFORMATION RIGHTS Unless otherwise required by law, your health record is the physical property of the healthcare practitioner or facility that compiled it. However, you have certain rights with respect to the information.

You have the right to: 1. Receive a copy of this Notice of Privacy Practices from us upon enrollment or upon request. 2. Request restrictions on our uses and disclosures of your protected health information for treatment, payment and health care operations. However, we reserve the right not to agree to the requested restriction. 3. Request to receive communications of protected health information in confidence. 4. Inspect and obtain a copy of the protected health information contained in your medical and billing records and in any other Practice records used by us to make decisions about you. A reasonable copying charge may apply. 5. Request an amendment to your protected health information. However, we may deny your request for an amendment, if we determine that the protected health information or record that is the subject of the request: • was not created by us, unless you provide a reasonable basis to believe that the originator of the protected health information is no longer available to act on the requested amendment; • is not part of your medical or billing records; • is not available for inspection as set forth above; or • is accurate and complete. In any event, any agreed upon amendment will be included as an addition to, and not a replacement of, already existing records 6. Receive an accounting of disclosures of protected health information made by us to individuals or entities other than to you, except for disclosures: • to carry out treatment, payment and health care operations as provided above; • to persons involved in your care or for other notification purposes as provided by law; • to correctional institutions or law enforcement officials as provided by law; • for national security or intelligence purposes; • that occurred prior to the date of compliance with privacy standards (April 14, 2003); • incidental to other permissible uses or disclosures; • that are part of a limited data set (does not contain protected health information that directly identifies individuals); • made to patient or their personal representatives; • for which a written authorization form from the patient has been received 7. Revoke your authorization to use or disclose health information except to the extent that we have already been taken action in reliance on your authorization, or if the authorization was obtained as a condition of obtaining insurance coverage and other applicable law provides the insurer that obtained the authorization with the right to contest a claim under the policy. 8. Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law. If you have provided us with a current e-mail address, we may use e-mail to communicate information related to the breach. OUR RESPONSIBILITIES We are required to maintain the privacy of your health information. In addition, we are required to provide you with a notice of our legal duties and privacy practices with respect to information we collect and maintain about you. We must abide by the terms of this notice. We reserve the right to change our practices and to make the new provisions effective for all the protected health information we maintain. If our information practices change, a revised notice will be mailed to the address you have supplied upon request. If we maintain a Web site that provides information about our patient/customer services or benefits, the new notice will be posted on that Web site. Your health information will not be used or disclosed without your written authorization, except as described in this notice. Except as noted above, you may revoke your authorization in writing at any time.

FOR MORE INFORMATION OR TO REPORT A PROBLEM If you have questions about this notice or would like additional information, you may contact our Privacy Officer at the telephone or address below. If you believe that your privacy rights have been violated, you have the right to file a complaint with the practice’s Privacy Officer or with the Secretary of the Department of Health and Human Services. The DHHS complaint form may be found at You will not be penalized in any way for filing a complaint.The contact information for both is included below. Infant Instincts Jessica Hopp, IBCLC Privacy Officer 6228 Filbert Ave Suite #1  Orangevale, CA 95662 916.827.5571

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