Restore Disclosure

HIPAA Policy

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed, and how you can gain access to this information. Please read carefully.


This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and controls your protected health information. “Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present or future health or condition and related health care services.


Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

FOR TREATMENT: We will use health information about you to furnish services and supplies to you, in accordance with our policies and procedures.

FOR PAYMENT: We may use and disclose health information about you to bill for our services and to collect payment from you or your insurance company. In addition, certain information may be released to a collection agency, if necessary, to collect payment from you.

FOR HEALTH CARE OPERATIONS: We may use and disclose information about you for the general operation of our business: Accreditation organizations, auditors or other consultants, for example. We may disclose protected health information about you in connection with certain public health reporting activities. We may disclose such information to a public health authority authorized to collect or receive PHI, for example, State health departments, Center for Disease Control, and the Food and Drug Administration to name a few. We are also permitted to disclose protected health information to a public health authority or other government authority authorized by law to receive reports of child abuse or neglect, domestic or elder abuse. Additionally, we may disclose PHI to a person subject to the Food and Drug Administration’s power for the following activities: to report adverse events, product defects or problems, or biological product deviations, to track products, to enable product recalls, repairs or replacements, or to conduct post-marketing surveillance. We may disclose PHI in connection with certain health oversight activities of licensing and other agencies. Health oversight activities include audit, investigation, inspection, licensure or disciplinary actions, and civil, criminal, or administrative proceedings or actions or any other activity necessary for the oversight of 1)the health care system, 2)governmental benefit programs for which health information is relevant to determining beneficiary eligibility, 3) entities subject to governmental regulatory programs for which health information is necessary for determining compliance with program standards, 4)entities subject to civil rights laws for which health information is necessary for determining compliance. We may disclose information in response to a warrant, subpoena, or other order of a court or administrative hearing body, and in connection with certain government investigations and law enforcement activities. If you are an inmate, we may release protected health information about you to a correctional institution where you are incarcerated or to law enforcement officials. Workers Compensation Programs. We may release your PHI to workers’ compensation or similar programs. Avoid Harm. PHI will be disclosed if necessary to prevent a serious threat to the health and safety of you or others. Research Purposes. We may use or disclose certain PHI about your condition and treatment for research purposes where and Institutional Review Board or a similar body referred to as a Privacy Board determines that your privacy interests will be adequately protected in the study. Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment or that you should schedule an appointment. Please note that no medical information or personal health information will be left on a recorder, voice mail or discussed with anyone other than you unless given permission in writing. Treatment Alternatives. We may use and disclose your personal health information in order to tell you about or recommend possible treatment options, alternatives or health-related services that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care. We may disclose information to individuals involved in your care or in the payment for your care, but we will obtain your agreement before doing so. This includes people and organizations that are part of your “circle of care”—such as your spouse, your other doctors, or an aide who may be providing services to you. Although we must be able to speak with your other physicians or health care providers, you can let us know if we should not speak with other individuals, such as your spouse or family members. We are required to obtain written authorization from you for any other uses and disclosures of medical information other than those described above. If you provide us with such permission, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose personal information about you for the reasons covered by your written authorization. We will be unable to take back any disclosures already made based upon your original permission.


The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask for restrictions on the uses and disclosures of your PHI beyond those imposed by law. We will consider your request, but we are not required to accept it. The Right to Choose How We Send PHI to You. You have the right to request that you receive communications containing your PHI from us by alternative means or locations, i.e. Email The Right to See and Get Copies of Your PHI. Except under certain circumstances, you have the right to inspect and copy medical and billing records about you. We may charge you a fee for copying and mailing. The Right to Get a List of the Disclosures We Have Made. You have a right to ask for a list of instances when we have used or disclosed your medical information for reasons other than your treatment, payment for services furnished to you, our healthcare operations, or disclosures you give us the authorization to make. If you ask for this information from us more than once every twelve months, we may charge you a fee.


If you think that we may have violated your privacy rights or you disagree with a decision we made about access to your PHI, you may file a complaint with Dr. K Naras Bhat or Dr. Imran Junaid. Please request the grievance from the office manager. It will be given directly to the providers for their immediate review and resolution. The Compliance Committee consists of the clinic staff. You may also send a written complaint to the Sec. of the Dept of Health and Human Service at 200 Independence Ave, SW, Room 509F, HHH Bldg., Washington, DC 20201. This clinic will not take any retaliatory action against you for filing a complaint about our privacy practices. If you have any questions about this notice or any complaints about our privacy practices or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact: JivaHealth, 2182 East Street, Concord, CA 94520.

Financial Policy

Method of Payment

We accept cash, check, and most major credit cards for your convenience. Returned checks are subject to a $25 NSF fee and we will no longer accept checks from patients who have written a returned NSF check. These patients will be asked to pay in an accepted alternative means such as credit card or cash for all future transactions.

New Patients and Referrals

Each patient’s primary care physician is responsible for coordinating his/her patient's health care. If you are seen without a referral, depending on your plan type, you may be responsible for payment for all services rendered. We encourage patients to know the requirements of their specific health plan. For new patients without insurance, payment in full at the time of service is required. For all patients with insurance, we require copays and prior deductibles to be paid at the time of service.

Usual & Customary Rate

Our clinic is committed to providing the best treatment possible for our patients. We charge what is usual and customary for our area. You are responsible for paying any balance in full, regardless of your insurance company’s determination of usual and customary rates.

Billing for Insurance Accounts

Verification of benefits is not a guarantee of payment or eligibility. If your insurance company pays differently for any reason than estimated, you agree that you are responsible to pay any remaining balance within 30 days of notification by your insurance company. If after 60 days from filing your claim we have not received payment from your insurance carrier, we ask you to pay the remaining balance on your account.


Every insurance carrier varies in reimbursement for medical weight management services, and coverage policies may vary from year to year. We recommend you contact your insurance carrier directly regarding coverage and out of pocket expenses. Once you have authorized Jiva Health to bill for medical weight management services, you are financially responsible for the cost of the extracts.

Below are the billing codes used for our Restore Weight management program for insurance reimbursement purposes.

MD Initial Visit (Initial and Monthly)
Code: 99203 or 99204, 99213 or 99214

Coach Visit (Initial and weekly)
Remote Patient Monitoring
Code: 99490, 99487, 99489
Code: 99453, 99454, 99457, 99458