THE PERFECT PUSH – PATIENT PRIVACY & CONSENT NOTICE

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At The Perfect Push (TPP), your privacy, safety, and trust matter deeply to us. This document explains how

we protect your health information, how we communicate with you, and the policies you agree to when

receiving care.

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1. HIPAA PRIVACY NOTICE

Federal law (HIPAA) requires healthcare providers to protect your Personal Health Information (PHI). PHI

includes any information related to your health, pregnancy, postpartum care, lactation support, or

services you receive from us.

How We May Use or Share Your Information

• We may use or share your PHI only when necessary for:

Treatment

• Sharing information with other healthcare providers involved in your care.

Payment

• Communicating with insurance companies or processing billing.

Healthcare Operations

Administrative work such as scheduling, quality improvement, or recordkeeping.

Any other use or disclosure requires your written permission.

Your Rights Under HIPAA

You have the right to:

• Access and review your medical records

• Request corrections or updates

• Receive a list of certain disclosures of your information

• Ask for limits on how your PHI is used or shared

• Request confidential communication (specific address or phone)

• Request that we do not share information with your insurer if you pay out of pocket in full

• Designate a personal representative to act on your behalf

• Receive updated versions of this notice if our practices change

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Our Responsibilities

We are required to:

• Maintain the privacy and security of your PHI

• Notify you if a breach of your information occurs

• Follow the privacy practices described in this notice

• Use or share information only as permitted unless you authorize otherwise in writing

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Privacy Officer Contact

Rue Khosa, ARNP, FNP-BC, IBCLC

HIPAA Privacy Officer

Phone: (945) 218-5688

Privacy Complaints

You may file a complaint without fear of retaliation or penalty.

You may contact Rue Khosa directly, or file with:

Office for Civil Rights U.S. Department of Health & Human Services

Phone: 1-800-368-1019

Website: https://www.hhs.gov/ocr

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2. UNSECURED COMMUNICATION POLICY & WEBSITE DATA COLLECTION

We strongly encourage communication through our secure patient portal or approved telehealth systems

whenever possible.

However, we recognize that clients may communicate with us through our website, email, text messaging,

or other electronic methods. This section explains how we collect, use, and protect personal information

submitted outside of our secure portal, including information collected through our website contact

forms.

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How We Collect Your Personal Information

We may collect personal information through:

• Website “Contact Us” forms

• Appointment request forms

• SMS/text message opt-in forms

• Email correspondence

• Phone calls and voicemail messages

• Secure patient portal communications

• Cookies or basic website analytics tools

• In-person or offline interactions

When you submit a form on our website, we typically collect your name, email address, and phone

number so we may respond to your inquiry and coordinate care.

 

What Personal Information We Collect

Depending on how you interact with us, we may collect:

• Name

• Email address

• Phone number

• Mailing address

• IP address (automatically collected through website analytics)

• Appointment details

• Health-related information you voluntarily provide

• Insurance information (when applicable)

• SMS communication preferences

We only collect information that is reasonably necessary to provide services, respond to inquiries, or

operate our practice.

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How We Use Your Personal Information

We use your information for the following purposes:

• Responding to inquiries submitted through our website

• Coordinating care and scheduling appointments

• Sending appointment reminders

• Providing follow-up instructions

• Sending time-sensitive care-related updates

• Processing payments

• Improving our website and user experience

• Maintaining medical records

• Complying with legal and regulatory requirements

We do not sell your personal information.

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SMS/Text Messaging Consent

By checking the opt-in box on our website forms, you agree to receive text messages from The Perfect

Push, PLLC related to:

• Coordination of care

• Appointment scheduling

• Appointment reminders

• Follow-up instructions

• Form confirmations

• Time-sensitive care-related updates

You may reply STOP at any time to opt out.

Reply HELP for assistance.

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Messages and data rates may apply. Message frequency will vary.

Learn more on our Privacy Policy page and Terms & Conditions.

Mobile opt-in, SMS consent, and phone numbers collected for SMS communication purposes

will not be shared with any third party or affiliates for marketing purposes.

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How, Why, and What Personal Information We Share with Third Parties

We may share limited personal information only when necessary and only with trusted service providers

who assist in operating our practice, such as:

• Secure electronic medical record platforms

• HIPAA-compliant telehealth providers

• Billing and payment processors

• Website hosting services

• IT service providers

We share information only for legitimate business or healthcare purposes, including providing services,

processing payments, and maintaining secure systems.

We do not share your personal information with third parties for marketing purposes.

We may also disclose information when required by law, court order, or public health reporting

requirements.

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3. UNSECURED COMMUNICATION POLICY

We strongly encourage communication through our secure patient portal or approved telehealth systems.

If you choose to communicate through:

• Email

• Text message

• Social media messaging

• Third-party apps

You understand that these methods may not be fully secure.

By choosing these options, you acknowledge the risks and agree that The Perfect Push is not

responsible for any privacy breach that occurs through unsecured communication.

 

4. CONSENT TO SHARE INFORMATION & DOCUMENTATION

All clinical notes are stored securely in a HIPAA-compliant system.

At intake, you may choose to opt in or out of the following:

• Use of notes to support your personalized care

• Documentation for your personal or family reflection

• Anonymous use of notes for professional education, certification, or training purposes

Your preferences will always be respected.

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5. CONSENT & ACKNOWLEDGMENT

By signing your service agreement and intake forms, you confirm that you:

• Have read and understood this notice

• Agree to its terms and conditions

• Accept responsibility for your chosen communication methods

• Voluntarily participate in care and related policies

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6. SEVERABILITY CLAUSE

If any provision of this Agreement is found to be invalid or unenforceable, the remaining provisions shall

remain in full force and effect.

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