How We May Use and Disclose Your PHI
We may use or disclose your Protected Health Information (PHI) for treatment, payment, and healthcare operations. This includes sharing information with pharmacies, labs, imaging centers, consultants, billing services, insurance plans, and other providers involved in your care. We may also disclose PHI when required by law such as public health reporting, abuse or neglect reporting, investigations, audits, legal processes, or law enforcement.
Additional Uses and Disclosures Required or Permitted by Law
We may disclose PHI without your authorization for public health activities, health oversight, judicial and administrative proceedings, law enforcement purposes, organ donation, coroners and funeral directors, workers’ compensation, research(with appropriate approvals), or to prevent a serious threat to health or safety.
Uses and Disclosures Requiring Your Authorization
We will not use or disclose your PHI for marketing, sale of information, psychotherapy notes, or any purpose not described in this Notice without your written authorization. You may revoke your authorization at any time in writing.
Your Rights Regarding Your PHI
You have the right to access and receive a copy of your medical record, request corrections, request confidential communication preferences, request restrictions on certain disclosures (we are not required to agree to all requests except for self-paid services), request an accounting of disclosures, and receive a paper copy of this Notice by written request. Since Harvest Family Health also operates as a telehealth practice, paper copies will only be mailed upon receipt of a formal written request.
Telehealth, Home Visits, and Electronic Communications
We use HIPAA-compliant systems for telehealth and secure messaging. You are responsible for participating from a private location. Email and text messaging are not fully secure; sensitive or clinical information should always be delivered through secure platforms. If you elect to send personal health information using a non-secure method, you grant permission to the recipient of your message to reply to your inquiry and acknowledge that any exchange of your information is not secure. We will never sell your information.
Our Responsibilities
We are required to maintain the privacy and security of your PHI, provide you with this Notice, notify you of any breach of unsecured PHI, and follow the terms of this Notice. We will not use or disclose your information in ways not described here without your authorization.
Questions or Complaints
If you have questions or believe your privacy rights have been violated, contact our business office:
Harvest Family Health, PLLC
3731 W South Jordan Parkway, Ste 102-429, South Jordan, Utah 84009
Phone: 801-923-6678 | Fax: 801-749-0204 | Email: info@harvestfamily.health
You may also contact the U.S. Department of Health & Human Services, Office for Civil Rights. We will not retaliate for filing a complaint.
Creation Date: November 15, 2025 | Revision Date: December 31, 2025
Consent to Medical Evaluation and Treatment
I voluntarily consent to receive medical care from Harvest Family Health, PLLC. This includes assessment, diagnosis, treatment, prescribing medications, ordering labs or imaging, care coordination, and health counseling. I understand I may withdraw consent at any time, which will not affect care already provided.
Care Delivery Methods: In-Clinic, Telehealth & Limited Home Visits
I understand Harvest Family Health provides care through in-person visits, via telehealth services including video visits, secure messaging, phone consultations, and limited home visits available only to established patients within a defined service area. Telehealth and home visits may limit physical examination, and my clinician may recommend an in-clinic visit or emergency evaluation if my condition cannot be adequately assessed or treated virtually or in the home setting. This consent applies to all modes of care unless I revoke it in writing.
Consent for Communication
The clinic communicates through phone, secure messaging, email, and text. I understand email and text are not fully secure and are used only for non-clinical communication unless I request otherwise. I may update my communication preferences at any time.
Financial Responsibility
I understand Harvest Family Health operates as a cash-pay clinic, and full payment is due at the time services are provided. The clinic does not bill insurance on my behalf. I may choose to submit documentation to my insurance for potential reimbursement, but the clinic cannot intervene or guarantee reimbursement.
Consent for Release of Information
I authorize the release of my health information for treatment, payment, and healthcare operations, including coordination with labs, imaging, pharmacies, and other providers. The clinic will never sell my information.
Risks, Benefits, and Alternatives
I understand all medical treatments have risks and benefits. Alternatives may exist, including delaying care or seeking in-person evaluation. I may ask questions at any time and have them answered to my satisfaction.
Emergency Limitations
Harvest Family Health does not provide emergency medical services. If I experience an emergency, I agree to call 911 or go to the nearest emergency department.
Patient Responsibilities
I agree to provide truthful and complete health information, update the clinic on changes in my condition, maintain accurate contact and pharmacy information, and use telehealth and communication tools appropriately. I understand that home visits require a safe, private, and appropriate environment and that I (or my child, accompanied by a parent or legal guardian) must be present during the visit.
Pediatric Patients (if applicable)
For minors, a parent/legal guardian must provide consent and be available during visits unless otherwise allowed by law. Limited home visits for minors require a parent or legal guardian to be physically present.
Acknowledgment and Agreement
By providing electronic acknowledgment or signature through Elation Health, I confirm I have read and understand this Consent to Treat and agree to receive care from Harvest Family Health, PLLC. Electronic acknowledgment has the same legal effect as a handwritten signature.
Effective Date: November 15, 2025 | Revision Date: January 13, 2026