Notice of Privacy

Notice of Privacy Practices
8/31/04

Keeping our client’s personal health information secure is a top priority for us at Smart Nutrition by Karen Graham, LLC. While information is the cornerstone of our ability to provide superior medical nutrition therapy (MNT) services, our most important asset is
our client’s trust. This notice tells you how we collect, handle, and disclose personal health information about you. If you want to limit our disclosing of this information, please submit your wishes to us in writing.

Our Policies and Practices to Protect
Your Personal Health Information

We protect personal health information we collect about you by maintaining physical, electronic, and procedural safeguards that meet or exceed applicable law.

Protected Health Information We Collect and May Disclose

The protected health information we collect about you comes from the following sources:

  • Information received from your physician or other healthcare provider.
  • Information we receive from you while providing MNT services and on enrollment forms,assessment surveys, or other forms.
  • Information we receive from other sources such as caregiver, insurer, employer and other third parties.

We may disclose any of your protected health information to the following entities as long as this information is directly related to health services or your individual care. These entities include doctors, hospitals, health care providers, pharmacies, insurance companies, family members or other persons involved directly in your individual care.
Protected health information will not be used for marketing, except if the communication is by a Smart Nutrition by Karen Graham, LLC staff member directly to you or to provide you with education or promotional material from Smart Nutrition by Karen Graham, LLC.

Your protected health information may be disclosed in the form of a “limited data set” for research, public health, and health care operations. A “limited data set” does not contain any direct identifiers of individuals (e.g. should not include name, address, phone number, social security number, medical number, etc.), but may contain any other demographic or health information needed for research public health or health care operations purposes.

By entering my name below and submitting this document I understand and acknowledge receipt of the above Notice of Privacy Practices. I also authorize the payment of medical and government benefits to Smart Nutrition by Karen Graham, LLC for MNT Services received.

Your Name


P.O. Box 6394
Scottsdale, AZ 85261
Phone: 480-659-0748 Email: karen@smartnutritionbykg.com Fax: 480-659-0748