Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
About This Notice
This Notice will tell you about the ways we may use and disclose health information that identifies you. We also describe your rights and certain obligations we have regarding the use and disclosure of Health Information. We are required by law to maintain the privacy of Health Information that identifies you; give you this Notice of our legal duties and privacy practices with respect to your Health Information; and follow the terms of our Notice that are currently in effect.
The following categories describe different ways that we may use and disclose Health Information:
For purposes of treatment: I understand that Northshore Acupuncture will use my health care information to treat me, including diagnosis and treatment. Treatment may include acupuncture, massage and herbs. I understand that for the purposes of diagnosis and treatment my protected health information may be disclosed but not sold to another health care provider. I understand that Northshore Acupuncture does its best to protect my medical information, but that in acupuncture group treatment and massage clinic care is administered in an open-room setting, thus other people may hear or see my treatment.
For payment services: I understand that my health care information may be used to receive payment for services and products. The information on or accompanying the bill may include my identification, as well as the herbs I am taking.
For health care operations: I understand that my protected health information may be disclosed for all activities that are included within the definition of “health care operations” as defined in the federal Privacy Regulations. For example, Northshore Acupuncture may use information in my health record to monitor the quality of supervision and student performance and to train acupuncture personnel.
Patient Care Research: I understand that Northshore Acupuncture performs patient care research at this clinic. All studies use strict ethical guidelines and undergo an ethical review process. These studies can be important for improving care in the future. Beginning today, I agree to allow my information to be used for studies of this kind. I understand that my privacy will always be protected. I understand that I may ask Northshore Acupuncture to stop using my information for research purposes at any time in the future. If I choose to stop participating, I will let the Clinic Director know in writing.
For fund development: I understand that Northshore Acupuncture is allowed by HIPAA regulations to use certain information (name, address, telephone numbers, dates of service, age, gender) to contact patients regarding efforts to raise funds to expand and improve the services and programs provided to the community. I understand that my willingness to engage in fund raising events will have no effect on my clinical care and I may opt out at any time. Requests must be made in writing and submitted to the Northshore Acupuncture HIPAA Compliance and Privacy Office.
Friends and family: Northshore Acupuncture may disclose protected health information to friends and family in case of an emergency to the extent necessary to help with health care or with payment of health care. Using their judgment as health care professionals, the acupuncture staff may disclose protected information with a family member, other relative, close personal friend, or any person identified as being involved in your health care.
Reminder calls: Northshore Acupuncture may contact you to provide reminders of herbal refills or appointments or other health related services that may be of interest to you.
Other covered entities: Northshore Acupuncture may disclose your protected health information to another covered entity to conduct health care operations in the area of quality assurance activities, or accreditation, certification, licensing or credentialing.
Disclosure to the U.S. Department of Health and Human Services: When the U.S. Department of Health and Human Services is investigating or determining our compliance with the federal Privacy Regulations, Northshore Acupuncture is required to disclose your protected health information to the DHHS.
Abuse or neglect: As an institution of higher learning, mandatory reporting rules require that we disclose protected health care information to appropriate authorities if we believe that an elderly individual or child may be a possible victim of abuse, domestic violence, neglect, or other crimes.
Serious threat to health or safety: We may disclose your protected health information if we believe that the disclosure is necessary to prevent a serious threat to your health or safety or the health and safety of the public or another person.
Public health and safety: Northshore Acupuncture may release your protected health information to public health or legal authorities charged with preventing or controlling disease, injury or disability. For example, we may use information in your health record to the Food and Drug Administration relative to adverse events regarding drugs, foods, supplements, and other health products or to post marketing surveillance to enable product recalls, or replacements.
Business Associates: We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
Worker’s compensation: We may release your protected health information if you are involved in a workman’s compensation case.
Law enforcement: Northshore Acupuncture may disclose your protected health information to law enforcement agencies in response to a court order, subpoena, discovery request, administrative order, or other lawful process by another person involved in a dispute involving a patient, but only if efforts have been made to tell the patient about the request or to obtain an order protecting the requested health information.
Other required or permitted disclosures: Northshore Acupuncture may disclose your health care information under the following circumstances:
- Whenever required to do so by law;
- To a correctional institution or its agents, if a patient is or becomes an inmate of such an institution, when necessary for the patient’s health or the health and safety of others;
- To notify, or assist in notifying a family member, personal representative, or another person responsible for the patient’s care or the patient’s location, or general condition;
- To the military authorities under certain circumstances when the patient is a member of the Armed Forces;
- To authorized federal officials for intelligence, counterintelligence, and other national security activities; for compliance audits by regulatory bodies or payers.
Authorized Use and Disclosure
I understand that Northshore Acupuncture will obtain my written Authorization before using or disclosing my protected health care information for purposes other than those listed above or otherwise permitted or required by law. I may revoke an Authorization in writing at any time. Upon receipt of this revocation Northshore Acupuncture will stop using or disclosing my protected health care information except to the extent that Northshore Acupuncture may have already taken action in reliance on previous authorization.
Guidelines around providing protected health information to an Northshore Acupuncture practitioner via e-mail
Information you submit through use of your own e-mail program is not secure. As effective as modern security practices are, no physical or electronic security system is impenetrable. We cannot guarantee the security of our electronic information systems, nor can we guarantee that information you supply won't be intercepted while being transmitted over the Internet. If you choose to send confidential or protected information over the internet, you do so solely at your own risk. Patients who choose to use the Internet to send protected information must must have signed documentation in their file stating they recognize their information is at risk of protected health information (PHI) breach.
Right to request restrictions: I understand that I have the right to request that Northshore Acupuncture restrict how my protected health information is used or disclosed in carrying out treatment, payment, or health care operations. Requests must be made in writing to the Northshore Acupuncture HIPAA Compliance and Privacy Office (see below). The request must tell Northshore Acupuncture: 1) the information to be limited and disclosed and 2) how I want Northshore Acupuncture to limit and/or disclose the information. I understand that Northshore Acupuncture is not required to agree to the requested restrictions, but if it does, Northshore Acupuncture will abide by the agreement except in an emergency.
Right to access protected health information: I understand that have the right to look at or obtain a confidential copy of my protected health information or billing/payment information. Requests must be made in writing to the Northshore Acupuncture HIPAA Compliance and Privacy Office (see below). Northshore Acupuncture may charge me a reasonable fee for copies and postage (if mailed). Northshore Acupuncture may deny my request to inspect and copy my protected health information in certain limited circumstances. If denied access to my protected health information, I may request that the denial be reviewed.
Right to access to electronic medical records: At this time, patient medical records have not been stored electronically and therefore electronic medical records cannot be provided to Northshore Acupuncture patients.
Accounting of Disclosures: I understand that I have the right to receive an accounting of the disclosures of my protected health information (PHI) Northshore Acupuncture has made on or after April 14, 2003. Northshore Acupuncture will provide the date of the disclosures, the name of the person or entity to which my PHI was disclosed, a description of the PHI disclosed, and the reason for the disclosure. Effective in September 2013, I have the right to restrict disclosures to an insurance company when I have paid for treatment out-of-pocket. Restriction requests must be made in writing and submitted to the Northshore Acupuncture HIPAA Compliance and Privacy Office.
Amendments to Health Care Information: I understand that I have the right to request that Northshore Acupuncture amend my protected health information if I feel that it is incomplete or incorrect. Requests must be made in writing to the Northshore Acupuncture Privacy Office (see below) and explain why the information should be amended. If Northshore Acupuncture did not create the information I want amended or in certain other circumstances, Northshore Acupuncture may deny the request. If the request is denied, a written explanation will be provided. I have the right to file a statement of disagreement with the decision.
How to Learn About Special Protections for HIV, Alcohol and Substance Abuse, Mental Health and Genetic Information: Special privacy protections apply to HIV-related information, alcohol and substance abuse information, mental health information, and genetic information. Some parts of this general Notice of Privacy Practices may not apply to these types
of information. If your treatment involves this information, you may contact the Privacy Officer for more information about these protections.
Privacy Breach Notification: You have the right to be notified if a breach occurs that may have compromised the privacy or security of your Health Information.
For More Information or to Report a Problem
I understand that if I would like additional information or have questions the privacy practices, I may contact the Northshore Acupuncture HIPAA Compliance and Privacy Office (see below). If I believe my privacy rights have been violated, I may file a complaint with Northshore Acupuncture or with the Department of Health and Human Services. I understand that Northshore Acupuncture supports my right to protect the privacy of my protected health and financial information and will not retaliate in any way if I choose to file a complaint with Northshore Acupuncture or with the Department of Health and Human Services.
Changes To This Notice
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for Health Information we already have, as well as any information we receive in the future. We will post a copy of the current Notice at each Northshore Acupuncture clinic office or outpatient location and on our website.
Northshore Acupuncture HIPAA Compliance and Privacy Officer
Teresa Fons, LAc