Notice of Privacy Practice – HIPAA
Privacy Practice
Acknowledgment & Consent Form
Acknowledgment & Consent Form
Dysport® is a highly effective cosmetic treatment that targets wrinkles and fine lines to restore a youthful, refreshed appearance. At Refresh Your Beauty, under the expert care of Dr. Leonel Calderon, our skilled provider specializes in offering Dysport® injections, helping clients achieve smoother, more rejuvenated skin. Whether you’re looking to treat frown lines, crow’s feet, or forehead wrinkles, Dysport® delivers quick, noticeable results with minimal downtime.
By relaxing specific facial muscles, Dysport® smooths out fine lines, helping you achieve a more vibrant and natural look. Dr. Calderon and our experienced team are dedicated to enhancing your beauty through non-surgical, customized treatments that help you feel your best. Let Refresh Your Beauty bring out your natural radiance with Dysport®.
Information We Collect
We collect personal and health-related information to provide safe and effective care. This may include:
• Full name, date of birth, contact information, and insurance details
• Health history and treatment records
• Photos taken for documentation (with separate consent)
• Payment and billing information
How We Use and Share Your Information
Your health information may be used and shared:
• For treatment, to provide and coordinate your care
• For payment, including billing you or a third party
• For healthcare operations, such as quality improvement and staff training
• When required by law (e.g., subpoenas, public health reporting)
We comply with additional protections under Florida law, including but not limited to Chapter 456,
Florida Statutes.
We will not sell, share, or disclose your PHI for any other purpose without your written consent, unless
permitted or required by law.
Your Rights
You have the right to:
• Access and request a copy of your health records
• Request corrections to inaccurate or incomplete information
• Request a restriction on certain uses or disclosures
• Request confidential communications (e.g., by mail or phone)
• Obtain an accounting of disclosures made outside of treatment, payment, or operations
• File a complaint if you believe your privacy rights have been violated
You may contact our Privacy Officer at the address above or file a complaint with the U.S. Department of
Health and Human Services.
Consent for Treatment & Use of PHI
By signing below, you:
• Authorize Refresh Your Beauty® Aesthetic Medicine Boutique, LLC to use and share your
protected health information for treatment, payment, and operations.
• Understand that you may revoke this consent in writing at any time, but revocation will not
apply to actions taken prior to the revocation.
• Acknowledge that you have received or been offered a copy of our Notice of Privacy Practices.
Photo Release (Optional – Separate Authorization Required)
Photographs may be taken for medical documentation, treatment planning, or outcome tracking. A
separate photo release form will be provided and must be signed before any images are used or retained.
Marketing & Communication
We may use your contact information to send appointment reminders or information related to your
treatment.
We will not send marketing materials about unrelated products or services without your separate,
signed authorization, as required by HIPAA.
Patient/Client Acknowledgment and Consent
I acknowledge and understand the policies stated above, and I authorize the use and disclosure of my
protected health information for treatment, payment, and healthcare operations.