THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION.
PLEASE REVIEW IT CAREFULLY.
We understand that health information about you and your health is personal. We are committed to protecting health information about you. We keep a record of the care you receive and services you receive from us. We need this record to provide you with quality care and to comply with legal requirements. This notice applies to all of the records pertaining to your care generated by this office. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights and our obligations regarding the use and disclosure of your health care information.
OUR RESPONSIBILITIES
We are required by law to maintain the privacy of your health information and provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you. We must abide by the terms of the notice of privacy practices currently in effect. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain.
OUR PRIVACY CONTACT
For further information about matters covered by this notice, please contact this office. Please send all written correspondence to the following address: 101 Edward Street, Burlington, WI 53105.
HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:
For Treatment: We may use health information about you to communicate with other health care providers such as MD/DO physicians.
For Payment: We may use health information about you so that the services you receive may be billed to a health insurance carrier or third-party provider. The information on the bill or any record included will identify you as well as indicate the diagnosis, procedures used, and herbal formulas and/or supplements purchased.
For Health Care Operations: We may disclose health information to another health care provider in order for us evaluate our treatment plan and review our services. This information will be obtained in an effort to improve the quality and effectiveness of services provided to you.
Appointment Reminders: We may use health care information to contact you as a reminder of an appointment for health care services.
As Required by Law: If required by federal, state, and/or municipal laws, we will disclose your health information.
Public Health: If required by federal, state, and/or municipal laws, we may disclose health information about you for public health and safety reason; We may have to report a communicable disease or notify an authority about any incident of abuse or neglect.
Lawsuits and Disputes: If involved in a lawsuit, we may disclose health information about you in response to a court or administrative order such as a subpoena, discovery request, or any other legal process under certain circumstances.
Deceased Patients: We may release information to the personal representative or spouse of a deceased patient. We may also release health information to a coroner or medical examiner, if requested. We may also release health information about patients to funeral directors, consistent with applicable law, to carry out their duties.
Organ and Tissue Donation: We may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs, consistent with applicable law, for the purpose of tissue donation and transplant.
Research: Under certain circumstances, we may use health information about you for research purposes.
Marketing: We may use your health information to inform you of services/programs/articles that may be of interest to you.
Food and Drug Administration (FDA): We may disclose to the FDA any health information related to any adverse events with respect to defective products or food supplements and/or inform you of information received through their surveillance.
Worker Compensation: We may release health information either through your written authorization or in compliance with laws related to a worker compensation claim.
Correctional Institution: We may release information for health and safety reasons if you are an inmate of a correctional institution.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
Rights to Request Restrictions: You have the right to request a restriction or limitation on the health information we disclose about you for treatment, payment, or health care operation. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or in the payment of your care like a friend or family member. If you would like to restrict any health care information, the request must in writing. Any requests to restrict health information are subject to discretion, as in the case of a medical emergency.
Rights to Request Confidential Communications: You have the right to request that we communicate with you about health care matters in a certain way and in a certain location. To request confidential communications, it must be a written one.
Right to Inspect and Copy: You have the right to inspect and obtain copies of health care records that may be used in decisions about your health care. You have a right to authorize another individual/health care provider to inspect and obtain copies of your health care records. A written authorization form must be completed and signed. A fee may be charged for costs in copying and/or mailing these records.
Right to Amend: If you think your health information is incorrect or incomplete, you may ask us to amend your record. You must provide a reason to support your request, and your request must be a written one. Your request to amend certain information may be denied because the person who created the records is unavailable to change it; the information contained in the records was that of another health care provider; or the health information provided was accurate and complete.
Right to Accounting of Disclosures: You have the right to request an “accounting of disclosures” of protected health information. To request an “accounting of disclosures,” it must be a written one. Your request must state a time period not to exceed six years. A fee may be charged for the costs in copying and/or mailing these records.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint, it must be a written one. There is no retaliation or penalty in filing a complaint.
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BRUISING RISK FACTS
Please be aware that any medical treatment that inserts a needle into the skin can result in bruising. Acupuncture needles are solid with cone shaped tips whereas hypodermic needles are hollow with sharp tips. Acupuncture needles are designed to penetrate painlessly into the tissue while hypodermic needles are designed to disperse/remove tissue in order to allow the insertion or extraction of fluids. With whatever needle used, even the relatively painless acupuncture needle, there is still a chance of bruising.
Please be aware that there may sensation after the insertion and removal of a needle.
Point stimulation doesn’t stop immediately after the removal of a needle. There may be a feeling as if the point is still “active” after treatment has ended.
All medical procedures/treatments have their risks and benefits. By signing the patient consent form, you have acknowledged the risks. In case of bruising, apply a homeopathic Arnica ointment or wrap an ice cube in a wash cloth and apply it to the site.
OFFICE POLICIES
CANCELLATION: Please notify me at 773-677-8458 if you must cancel/reschedule an appointment within 24 hours, unless there is an emergency. As a courtesy in 2014, the office policy will be that there will be no charge for the 1st missed appointment. The charge for any subsequent missed appointments will be as follows: 2nd missed appointment $20.00; 3rd missed appointment $40.00; and 4th missed appointment $60.00. After the 4th missed appointment, the practitioner at her discretion may discharge the patient from any further care. Thank you.