NOTICE​ ​OF​ ​PRIVACY​ ​PRACTICES​ ​–​ ​ACKNOWLEDGMENT

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We​ ​understand​ ​that​ ​medical​ ​information​ ​about​ ​you​ ​and​ ​your​ ​health​ ​is​ ​personal​ ​and​ ​we​ ​are committed​ ​to​ ​protecting​ ​this​ ​information.​ ​When​ ​you​ ​receive​ ​acupuncture​ ​treatment,​ ​a​ ​record​ ​of the​ ​treatment​ ​is​ ​made.

Typically,​ ​this​ ​record​ ​contains​ ​your​ ​treatment​ ​plan,​ ​your​ ​history​ ​and​ ​physical,​ ​any​ ​other information​ ​that​ ​you​ ​provide​ ​to​ ​us,​ ​and​ ​billing​ ​records.​ ​This​ ​record​ ​serves​ ​as​ ​a:

1. Basis​ ​for​ ​planning​ ​your​ ​treatment;

2. A​ ​record​ ​for​ ​assessing​ ​improvement;

3. A​ ​tool​ ​for​ ​assessing​ ​and​ ​continually​ ​working​ ​to​ ​improve​ ​the​ ​care​ ​rendered.

 

YOUR​ ​RIGHTS

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When​ ​it​ ​comes​ ​to​ ​your​ ​health​ ​information,​ ​you​ ​have​ ​certain​ ​rights.​ ​This​ ​section​ ​explains​ ​your rights​ ​and​ ​some​ ​of​ ​our​ ​responsibilities​ ​to​ ​help​ ​you.

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Get​ ​an​ ​electronic​ ​or paper​ ​copy​ ​of​ ​your medical​ ​record

● You​ ​can​ ​ask​ ​to​ ​see​ ​or​ ​get​ ​an​ ​electronic​ ​or​ ​paper​ ​copy​ ​of​ ​your medical​ ​record​ ​and​ ​other​ ​health​ ​information​ ​we​ ​have​ ​about you.​ ​Ask​ ​us​ ​how​ ​to​ ​do​ ​this.

● We​ ​will​ ​provide​ ​a​ ​copy​ ​or​ ​a​ ​summary​ ​of​ ​your​ ​health information,​ ​usually​ ​within​ ​30​ ​days​ ​of​ ​your​ ​request.​ ​We​ ​may charge​ ​a​ ​reasonable,​ ​cost-based​ ​fee.

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Ask​ ​us​ ​to​ ​correct your​ ​medical​ ​record

● You​ ​can​ ​ask​ ​us​ ​to​ ​correct​ ​health​ ​information​ ​about​ ​you​ ​that​ ​you think​ ​is​ ​incorrect​ ​or​ ​incomplete.​ ​Ask​ ​us​ ​how​ ​to​ ​do​ ​this.

● We​ ​may​ ​say​ ​“no”​ ​to​ ​your​ ​request,​ ​but​ ​we’ll​ ​tell​ ​you​ ​why​ ​in writing​ ​within​ ​60​ ​days.

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Request​ ​confidential communications

● You​ ​can​ ​ask​ ​us​ ​to​ ​contact​ ​you​ ​in​ ​a​ ​specific​ ​way​ ​(for​ ​example, home​ ​or​ ​office​ ​phone)​ ​or​ ​to​ ​send​ ​mail​ ​to​ ​a​ ​different​ ​address.

● We​ ​will​ ​say​ ​“yes”​ ​to​ ​all​ ​reasonable​ ​requests.

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Ask​ ​us​ ​to​ ​limit​ ​what we​ ​use​ ​or​ ​share

● You​ ​can​ ​ask​ ​us​ ​not​ ​to​ ​use​ ​or​ ​share​ ​certain​ ​health​ ​information for​ ​treatment,​ ​payment,​ ​or​ ​our​ ​operations.​ ​We​ ​are​ ​not​ ​required to​ ​agree​ ​to​ ​your​ ​request,​ ​and​ ​we​ ​may​ ​say​ ​“no”​ ​if​ ​it​ ​would​ ​affect your​ ​care.

● If​ ​you​ ​pay​ ​for​ ​a​ ​service​ ​or​ ​health​ ​care​ ​item​ ​out-of-pocket​ ​in full,​ ​you​ ​can​ ​ask​ ​us​ ​not​ ​to​ ​share​ ​that​ ​information​ ​for​ ​the purpose​ ​of​ ​payment​ ​or​ ​our​ ​operations​ ​with​ ​your​ ​health​ ​insurer. We​ ​will​ ​say​ ​“yes”​ ​unless​ ​a​ ​law​ ​requires​ ​us​ ​to​ ​share​ ​that information.

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Get​ ​a​ ​list​ ​of​ ​those with​ ​whom​ ​we’ve shared​ ​information

● You​ ​can​ ​ask​ ​for​ ​a​ ​list​ ​(accounting)​ ​of​ ​the​ ​times​ ​we’ve​ ​shared your​ ​health​ ​information​ ​for​ ​six​ ​years​ ​prior​ ​to​ ​the​ ​date​ ​you​ ​ask, who​ ​we​ ​shared​ ​it​ ​with,​ ​and​ ​why.

● We​ ​will​ ​include​ ​all​ ​the​ ​disclosures​ ​except​ ​for​ ​those​ ​about treatment,​ ​payment,​ ​and​ ​health​ ​care​ ​operations,​ ​and​ ​certain other​ ​disclosures​ ​(such​ ​as​ ​any​ ​you​ ​asked​ ​us​ ​to​ ​make).​ ​We’ll provide​ ​one​ ​accounting​ ​a​ ​year​ ​for​ ​free​ ​but​ ​will​ ​charge​ ​a reasonable,​ ​cost-based​ ​fee​ ​if​ ​you​ ​ask​ ​for​ ​another​ ​one​ ​within​ ​12 months.

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Get​ ​a​ ​copy​ ​of​ ​this privacy​ ​notice

● You​ ​can​ ​ask​ ​for​ ​a​ ​paper​ ​copy​ ​of​ ​this​ ​notice​ ​at​ ​any​ ​time,​ ​even​ ​if you​ ​have​ ​agreed​ ​to​ ​receive​ ​the​ ​notice​ ​electronically.​ ​We​ ​will provide​ ​you​ ​with​ ​a​ ​paper​ ​copy​ ​promptly.

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Choose​ ​someone​ ​to act​ ​for​ ​you

● If​ ​you​ ​have​ ​given​ ​someone​ ​medical​ ​power​ ​of​ ​attorney​ ​or​ ​if someone​ ​is​ ​your​ ​legal​ ​guardian,​ ​that​ ​person​ ​can​ ​exercise​ ​your rights​ ​and​ ​make​ ​choices​ ​about​ ​your​ ​health​ ​information.

● We​ ​will​ ​make​ ​sure​ ​the​ ​person​ ​has​ ​this​ ​authority​ ​and​ ​can​ ​act​ ​for you​ ​before​ ​we​ ​take​ ​any​ ​action.

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YOUR​ ​CHOICES

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For​ ​certain​ ​health​ ​information,​ ​you​ ​can​ ​tell​ ​us​ ​your​ ​choices​ ​about​ ​what​ ​we​ ​share.​​ ​If​ ​you have​ ​a​ ​clear​ ​preference​ ​for​ ​how​ ​we​ ​share​ ​your​ ​information​ ​in​ ​the​ ​situations​ ​described​ ​below,​ ​talk to​ ​us.​ ​Tell​ ​us​ ​what​ ​you​ ​want​ ​us​ ​to​ ​do,​ ​and​ ​we​ ​will​ ​follow​ ​your​ ​instructions.

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In​ ​these​ ​cases,​ ​you have​ ​both​ ​the​ ​right and​ ​choice​ ​to​ ​tell​ ​us to:

● Share​ ​information​ ​with​ ​your​ ​family,​ ​close​ ​friends,​ ​or​ ​others involved​ ​in​ ​your​ ​care

● Share​ ​information​ ​in​ ​a​ ​disaster​ ​relief​ ​situation.
● If​ ​you​ ​are​ ​not​ ​physically​ ​able​ ​to​ ​tell​ ​us​ ​your​ ​preference​ ​we​ ​may

go​ ​ahead​ ​and​ ​share​ ​your​ ​information​ ​if​ ​we​ ​believe​ ​it​ ​is​ ​in​ ​your best​ ​interest.​ ​We​ ​may​ ​also​ ​share​ ​your​ ​information​ ​when​ ​needed to​ ​lessen​ ​a​ ​serious​ ​and​ ​imminent​ ​threat​ ​to​ ​health​ ​or​ ​safety.

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Only​ ​if​ ​you​ ​give​ ​us written​ ​permission:

● Marketing​ ​purposes.

● Sale​ ​of​ ​your​ ​information.

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In​ ​the​ ​case​ ​of fundraising:

● We​ ​may​ ​contact​ ​you​ ​for​ ​fundraising​ ​efforts,​ ​but​ ​you​ ​can​ ​tell​ ​us not​ ​to​ ​contact​ ​you​ ​again.

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OUR​ ​USES​ ​&​ ​DISCLOSURES

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How​ ​do​ ​we​ ​typically​ ​use​ ​or​ ​share​ ​your​ ​health​ ​information?​​ ​We​ ​typically​ ​use​ ​or​ ​share​ ​your health​ ​information​ ​in​ ​the​ ​following​ ​ways.

Treat​ ​you

● We​ ​can​ ​use​ ​your​ ​health​ ​information​ ​and​ ​share​ ​it​ ​with​ ​other professionals​ ​who​ ​are​ ​treating​ ​you.

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Run​ ​our organization

● We​ ​can​ ​use​ ​and​ ​share​ ​your​ ​health​ ​information​ ​to​ ​run​ ​our practice,​ ​improve​ ​your​ ​care,​ ​and​ ​contact​ ​you​ ​when​ ​necessary.

Bill​ ​for​ ​your​ ​services

● We​ ​can​ ​use​ ​and​ ​share​ ​your​ ​health​ ​information​ ​to​ ​bill​ ​and​ ​get payment​ ​from​ ​you​ ​or​ ​another​ ​party.

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Identification

● We​ ​may​ ​require​ ​you​ ​to​ ​provide​ ​us​ ​certain​ ​information​ ​to​ ​verify your​ ​identification.​ ​We​ ​may​ ​use​ ​different​ ​methods​ ​to​ ​confirm your​ ​identification,​ ​including​ ​but​ ​not​ ​limited​ ​to,​ ​photographs, fingerprints​ ​or​ ​other​ ​biometrics.

● This​ ​information​ ​will​ ​be​ ​stored​ ​in​ ​our​ ​system​ ​for​ ​identification purposes​ ​only​ ​and​ ​will​ ​not​ ​be​ ​utilized​ ​for​ ​any​ ​other​ ​purposes.

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Appointment reminders

● We​ ​may​ ​use​ ​and​ ​disclose​ ​medical​ ​information​ ​to​ ​remind​ ​you​ ​of an​ ​appointment,​ ​if​ ​applicable.

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Comply​ ​with​ ​the​ ​law

● We​ ​will​ ​share​ ​medical​ ​information​ ​about​ ​you​ ​when​ ​required​ ​to do​ ​so​ ​by​ ​federal​ ​or​ ​state​ ​laws​ ​or​ ​regulations.

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Address​ ​workers’ compensation,​ ​law enforcement,​ ​and other​ ​government requests

● We​ ​can​ ​use​ ​or​ ​share​ ​health​ ​information​ ​about​ ​you:
● For​ ​workers’​ ​compensation​ ​claims.
● For​ ​law​ ​enforcement​ ​purposes​ ​or​ ​with​ ​a​ ​law​ ​enforcement official.
● With​ ​health​ ​oversight​ ​agencies​ ​for​ ​activities​ ​authorized​ ​by​ ​law.

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Do​ ​research

● We​ ​can​ ​use​ ​or​ ​share​ ​your​ ​information​ ​for​ ​health​ ​research.

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Respond​ ​to​ ​lawsuits and​ ​legal​ ​actions

● We​ ​can​ ​share​ ​health​ ​information​ ​about​ ​you​ ​in​ ​response​ ​to​ ​a court​ ​or​ ​administrative​ ​order,​ ​or​ ​in​ ​response​ ​to​ ​a​ ​subpoena.

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Our​ ​Responsibilities

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• ●  We​ ​are​ ​required​ ​by​ ​law​ ​to​ ​maintain​ ​the​ ​privacy​ ​and​ ​security​ ​of​ ​your​ ​protected​ ​health information.

• ●  We​ ​will​ ​let​ ​you​ ​know​ ​promptly​ ​if​ ​a​ ​breach​ ​occurs​ ​that​ ​may​ ​have​ ​compromised​ ​the privacy​ ​or​ ​security​ ​of​ ​your​ ​information.

• ●  We​ ​must​ ​follow​ ​the​ ​duties​ ​and​ ​privacy​ ​practices​ ​described​ ​in​ ​this​ ​notice​ ​and​ ​give​ ​you​ ​a copy​ ​of​ ​it.

• ●  We​ ​will​ ​not​ ​use​ ​or​ ​share​ ​your​ ​information​ ​other​ ​than​ ​as​ ​described​ ​here​ ​unless​ ​you​ ​tell​ ​us we​ ​can​ ​in​ ​writing.​ ​If​ ​you​ ​tell​ ​us​ ​we​ ​can,​ ​you​ ​may​ ​change​ ​your​ ​mind​ ​at​ ​any​ ​time.​ ​Let​ ​us know​ ​in​ ​writing​ ​if​ ​you​ ​change​ ​your​ ​mind.

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