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Consent & Acknowledgment Form

This form confirms that you, the client, understand and consent to Bella Marie Aesthetics HIPAA compliance, and data privacy practices. Please review each section carefully and sign below to acknowledge your understanding and agreement.


1. Acknowledgment of HIPAA Privacy and Data Policy

I acknowledge that I have received, read, and understand the Bella Marie Aesthetics HIPAA Privacy and Data Policy. I understand how my personal and health information will be used, stored, and protected in accordance with HIPAA regulations.


Your Privacy Rights Under HIPAA

This Notice describes how your medical information may be used and disclosed, and how you can access your information. Please review it carefully.


At Bella Marie Aesthetics, we are committed to protecting your privacy and ensuring that your personal health information (PHI) is kept confidential in compliance with federal and state laws, including the Health Insurance Portability and Accountability Act (HIPAA).


1a. Our Legal Duty

We are legally required to:

  1. Maintain the privacy of your Protected Health Information (PHI).
  2. Provide you with this Notice explaining our legal duties and privacy practices.
  3. Follow the terms of this Notice currently in effect.
  4. Notify you in the event of a breach of your unsecured PHI.


1b. How We May Use and Disclose Your PHI

We may use or share your PHI for the following purposes:


Treatment

To provide, coordinate, or manage your aesthetic and regenerative care.

Example: Sharing information with other healthcare professionals involved in your treatment.


Payment

To bill and collect payment for the services you receive.

Example: Sending information to your insurance provider or billing service.


Healthcare Operations

For clinic operations such as quality improvement, staff training, and compliance review.

Example: Reviewing treatment outcomes to improve services.


When Required by Law

We may disclose your PHI if required to do so by federal, state, or local law.


1c. Other Permitted and Required Uses and Disclosures

We may also use or disclose your PHI in the following situations without your authorization:


  1. Public health activities (e.g., reporting adverse events or product recalls).


  1. Health oversight activities (e.g., audits, inspections).


  1. Legal proceedings (e.g., in response to a court order).


  1. Law enforcement purposes (e.g., identifying a suspect or missing person).


  1. Serious threat to health or safety when necessary to prevent harm.


  1. Workers compensation claims.


Any other use or disclosure not covered by this Notice requires your written authorization. You may revoke that authorization in writing at any time.


1d. Your Rights Regarding Your PHI

You have the right to:


  1. Access your medical records: Request a copy of your PHI in paper or electronic form.


  1. Request corrections: Ask to amend any incomplete or inaccurate information.


  1. Request restrictions: Limit how we use or share your information (we are not required to agree to all restrictions).


  1. Request confidential communications: Ask that we contact you in a specific way (e.g., via email or phone).


  1. Receive an accounting of disclosures: See a list of instances where your PHI was shared for non-treatment purposes.


  1. Obtain a paper copy of this Notice at any time, even if you agreed to receive it electronically.


Requests can be made in writing to the Privacy Officer at the address below.


1e. Patient Confidentiality and Data Security


We use administrative, technical, and physical safeguards to protect your PHI, including:


  1. Encrypted digital record systems


  1. Access controls and staff training


  1. Secure communication and storage protocols


Only authorized staff and contractors bound by confidentiality agreements may access your information.


1f. Marketing and Communications


We may contact you about:


  1. Appointment reminders


  1. Treatment follow-ups


  1. New services or promotional offers


You may opt out of marketing communications at any time by notifying us via email or phone.


1g. Breach Notification


If your unsecured PHI is compromised due to a data breach, we will notify you promptly as required by HIPAA law, including details about the breach and steps you can take to protect yourself.


1h. Changes to This Notice


We reserve the right to revise this Notice at any time. Updates will be posted in our office and on our website with the new effective date.


1i. Questions or Complaints


If you have questions about this Notice or believe your privacy rights have been violated, you may contact:


Bella Marie Aesthetics

125 Murray Hill Rd, Suite C, Southern Pines, NC 28387

bellamarieaesthetics@gmail.com

(910) 886-2228


You may also file a complaint directly with the U.S. Department of Health and Human Services (HHS) Office for Civil Rights at:


  1. Website: https://www.hhs.gov/ocr/privacy/hipaa/complaints/
  2. Phone: 1-800-368-1019
  3. Mail: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington, D.C. 20201


You will not be penalized or retaliated against for filing a complaint.


2. Data Sharing and Privacy

I understand that Bella Marie Aesthetics does not share my personal or mobile information with third parties for marketing purposes under any circumstances.


My information is used solely for legitimate business and treatment-related purposes.



3. Use of Contact Information

I consent to the use of my phone number and email address for appointment reminders, treatment follow-ups, account verification, and necessary communications related to my care.



4. Prohibition on Data Transfer

I understand and agree that my data will not be transferred to any external organizations under any circumstances, even with my consent.



5. SMS Communications and Terms of Use


Types of SMS Messages You May Receive

You may receive the following types of text (SMS) messages from Bella Marie Aesthetics:


  1. Appointment confirmations and reminders


  1. Treatment follow-ups and post-care check-ins


  1. Account verification messages


  1. Occasional service updates or important notifications related to your care


Message Frequency

Message frequency varies based on your appointments and treatment needs. Generally, you may receive 14 messages per month, depending on your interactions with the clinic.


Message and Data Rates Notice

You will receive SMS messages related to your account and service updates. Message frequency varies. Message and data rates may apply according to your mobile carriers plan.


SMS Opt-Out InstructionsTo stop receiving SMS messages, reply STOP to any message.


For assistance, reply HELP or contact us directly at (910) 886-2228 or bellamarieaesthetics@gmail.com.


Opting out will stop all non-essential text messages but will not affect your ability to receive important updates about active treatments or appointments (if required by law or medical necessity).


Bella Marie Aesthetics

125 Murray Hill Rd, Suite C

Southern Pines, NC 28387

📞 (910) 886-2228

📧 bellamarieaesthetics@gmail.com



7. Acknowledgment and Signature

By signing below, I confirm that I have read and understood all policies and consent to treatment and communication as outlined above.



Thank you for trusting Bella Marie Aesthetics with your care and privacy.