Notice of Privacy Practices
Teapot Lactation, LLC
Tracy Potter RN, IBCLC
tracy@teapotlactation.com
(303) 919-6293
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
Ask us to correct your medical record
Request confidential communications
• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
Get a list of those with whom we’ve shared information
Get a copy of this
privacy notice
Choose someone
to act for you
File a complaint if
you feel your rights are violated
• You can ask us not to use or share certain health information for treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
• We will say “yes” unless a law requires us to share that information.
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• 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/.
• We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
In these cases we never share your information unless you give us
written permission:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
• Contact you for fundraising efforts
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes
In the case of fundraising: • We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
How do we typically use or share your health information? We typically use or share your health information in the following ways.
Treat you • We can use your health information and share it with other professionals who are
treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our
organization
Bill for your services
• We can use and share your health information to run our practice, improve your care, and contact you when necessary.
• We can use and share your health information to bill and get payment from health plans or other entities.
Example: We use health information about you to manage your treatment and services.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
• We can share health information about you for certain situations such as: • Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety
Do research • We can use or share your information for health research.
Comply with the law • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to
see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
Work with a medical examiner or funeral director
Address workers’
compensation, law
enforcement, and other government requests
Respond to lawsuits and legal actions
• We can share health information about you with organ procurement organizations.
• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
• We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services
• We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
This Notice of Privacy Practices applies to the following organizations.: Teapot Lactation, LLC
Tracy Potter RN, IBCLC: tracy@teapotlactation.com
Payment Policy
Teapot Lactation, LLC
All gift card sales are non-refundable and FINAL. A code will be provided for each gift card purchase, and this code is associated with a balance that may be applied to specific private pay visits. Gift cards are not reloadable and may not be transferred to another recipient at any time.
​
Self-pay (out-of-network) clients:
Tracy Potter RN, IBCLC will provide you with a superbill suitable for you to submit to your insurance. The superbill (which will also serve as a payment receipt) will be coded appropriately to the level of service provided during the visit. You agree to pay Tracy Potter RN, IBCLC at the time of the scheduling (cash, check, credit card, or FSA). Teapot Lactation LLC will assess a $50.00 returned check fee (per check) on all returned checks.
Tracy Potter RN, IBCLC is not responsible for communicating directly with my insurance company in reference to the services provided to me and my baby or babies. I understand that Tracy Potter RN, IBCLC does not directly bill my insurance and is not able to complete insurance forms such as gap exception coverage requests, etc. Tracy Potter RN, IBCLC may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment and insurance information. I will update my credit card information as needed and am responsible for any costs and fees associated with my failure to provide updated information.
Invoicing policy is as follows:
For all Private Pay visits, I understand that payment is due at the time of scheduling. My credit card will be charged at the time I schedule the appointment.
Any travel or mileage fees will be invoiced separately and Tracy Potter RN, IBCLC will charge the card on file after the visit is completed. These fees are not typically eligible for insurance reimbursement.
Lactation Network Clients: **PLEASE NOTE: TELEHEALTH VISITS ARE NOT INSURANCE BILLABLE FOR CLIENTS WITH UNITED HEALTHCARE (UHC) OR UMR POLICIES.** Claims for my care will be submitted directly through The Lactation Network. Tracy Potter RN, IBCLC will appeal all cost-sharing under the Affordable Care Act which states that lactation services are preventive and not subject to cost-sharing. If my insurance provider applies any portion to deductible or coinsurance and appeal attempts are unsuccessful, my credit card on file will be charged. If that charge is unsuccessful for any reason, I will be invoiced and I agree to pay within 7 days for all applied charges for all visits.
If one of us (me or my baby) is on different insurance and therefore out-of-network for Tracy Potter RN, IBCLC, I agree to pay the private pay amount (posted online) per visit. I will receive a superbill for this amount and can submit for out-of-network insurance. If I have different primary insurance that is out-of-network for Tracy Potter RN, IBCLC, I understand that I must pay the full self-pay fee up front as a deposit. I will not be refunded for any amount either insurance applies to cost-sharing. I will only be refunded if and when Tracy Potter RN, IBCLC receives payment directly from either insurance, and only for the specific amounts paid by my insurance(s). Tracy Potter RN, IBCLC may keep any amount paid by my insurance(s) over and above the deposit I paid.
Wildflower Health Clients:
Claims for my care will be submitted directly through Wildflower Health. Tracy Potter RN, IBCLC will appeal all cost-sharing under the Affordable Care Act which states that lactation services are preventive and not subject to cost-sharing. If my insurance provider applies any portion to deductible or coinsurance and appeal attempts are unsuccessful, my credit card on file will be charged. If that charge is unsuccessful for any reason, I will be invoiced and I agree to pay within 7 days for all applied charges for all visits.
If one of us (me or my baby) is on different insurance and therefore out-of-network for Tracy Potter RN, IBCLC, I agree to pay the private pay amount (posted online) per visit. I will receive a superbill for this amount and can submit for out-of-network insurance. If I have different primary insurance that is out-of-network for Tracy Potter RN, IBCLC, I understand that I must pay the full self-pay fee up front as a deposit. I will not be refunded for any amount either insurance applies to cost-sharing. I will only be refunded if and when Tracy Potter RN, IBCLC receives payment directly from either insurance, and only for the specific amounts paid by my insurance(s). Tracy Potter RN, IBCLC may keep any amount paid by my insurance(s) over and above the deposit I paid.
Aetna Insurance Clients (Primary Policies Only and based on pre-approval):
Claims for my care will be submitted directly to Aetna Health, Inc. Tracy Potter RN, IBCLC will appeal all cost-sharing under the Affordable Care Act which states that lactation services are preventive and not subject to cost-sharing. If my insurance provider applies any portion to deductible or coinsurance and appeal attempts are unsuccessful, my credit card on file will be charged. If that charge is unsuccessful for any reason, I will be invoiced and I agree to pay within 7 days for all applied charges for all visits.
Tracy Potter RN, IBCLC will submit a claim on behalf of myself and my babies. If any portion of either claim is applied to cost-sharing, I understand that I am required by law to pay cost-sharing to Tracy Potter RN, IBCLC. My credit card will be charged upon receipt of the Estimation of Benefits (EOB) by Tracy Potter RN, IBCLC. Every effort will be made to have my insurance recognize these claims as preventive and not subject to cost-sharing, and an appeal will be initiated. If successful, I will be refunded any amount that Tracy Potter RN, IBCLC recovers from my insurer.
If one of us (me or my baby) is on different insurance and therefore out-of-network for Tracy Potter RN, IBCLC, I agree to pay the self-pay fee listed per visit. I will receive a superbill for this amount and can submit for out-of-network insurance.
If I have different primary insurance that is out-of-network for Tracy Potter RN, IBCLC, I understand that I must pay the full self-pay fee up front as a deposit. I will not be refunded for any amount either insurance applies to cost-sharing. I will only be refunded if and when Tracy Potter RN, IBCLC receives payment directly from either insurance, and only for the specific amounts paid by my insurance(s). Tracy Potter RN, IBCLC may keep any amount paid by my insurance(s) over and above the deposit I paid.
All Clients:
Teapot Lactation, LLC is providing care to me and to my baby or babies; together we are all the client of Tracy Potter RN, IBCLC.
My initial visit includes 2 weeks of follow up support by secure messaging, email, or text. Continued support is available if I schedule an additional visit.
If my location has a travel fee applied, I understand that this is not eligible for insurance reimbursement.
Travel and mileage fees will be invoiced separately and I will charge the card on file after the visit is completed, typically within 4-6 hours.
I am responsible to verify my own lactation benefits. Tracy Potter RN, IBCLC can only see that I have benefits, they cannot see if I have any special circumstances that might prevent my insurance provider from covering services. If my plan denies coverage of lactation services after the claims have been submitted, I am responsible to pay at the self-pay rate. I understand I should refer to my plan benefits and call my insurance directly to verify lactation coverage.
Tracy Potter RN, IBCLC is not responsible for communicating directly with my insurance company in reference to the services provided to me and my baby or babies. I understand that Tracy Potter RN, IBCLC does not directly bill my insurance and is not able to complete insurance forms such as gap exception coverage requests, etc. Tracy Potter RN, IBCLC may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment and insurance information. I will update my credit card information as needed and am responsible for any costs and fees associated with my failure to provide updated information.
These policies apply to Teapot Lactation, LLC and its representatives.
If you use SquareUp: Payments may be made electronically using a credit card or fund transfer. I use SquareUp to process payments. SquareUp meets the high standards of HIPAA and the banking industry for security and privacy with regard to financial transactions. However, SquareUp may send, automatically or per your request, email or text message receipts that reveal personal health information such as the date and type of lactation visit.
If you are not comfortable with this, payment may be made via cash or check instead.
Cancellation and No-Show policy: I understand that I am responsible for all charges associated with this visit. If I cancel with less than 24 hours notice or fail to show up for my scheduled visit without notice, I will be charged $30.00 fee, billed to the card on file.