Notice of Privacy Practices

Doris Romero, DOM

Effective Date of Notice: January 20, 2017

Your Information. Your Rights. My Responsibilities.

I understand that medical information about you and your health is personal and I am 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. Means of communication for or between other health care providers, if any, that you wish us to share such information with.

YOUR RIGHTS

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

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 I have about you. Ask me 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.
Ask me to correct your medical record	You can ask me to correct health information about you that you think is incorrect or incomplete. Ask me how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications	You can ask me 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.
Ask me to limit what I use or share	You can ask me not to use or share certain health information for treatment, payment, or our operations. I am 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 me not to share that information for the purpose of payment or our operations with your health insurer. I will say “yes” unless a law requires me to share that information.
Get a list of those with whom I’ve shared information	You can ask for a list (accounting) of the times I’ve shared your health information for six years prior to the date you ask, who I shared it with, and why. I 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).I’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.
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. I will provide you with a paper copy promptly.
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. I will make sure the person has this authority and can act for you before I take any action.

YOUR CHOICES

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

In these cases, you have both the right and choice to tell me 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 me your preference I may go ahead and share your information if I believe it is in your best interest. I may also share your information when needed to lessen a serious and imminent threat to health or safety.
Only if you give me written permission:	Marketing purposes. Sale of your information.
In the case of fundraising:	• I may contact you for fundraising efforts, but you can tell me not to contact you again.

OUR USES & DISCLOSURES

How do I typically use or share your health information? I typically use or share your health information in the following ways.

Your treatments	• I can use your health information and share it with other professionals who are treating you.
Run our organization	• I can use and share your health information to run my practice, improve your care, and contact you when necessary.
Bill for your services	• I can use and share your health information to bill and get payment from you or another party.
Identification	I may require you to provide me certain information to verify your identification. I may use different methods to confirm your identification. This information will be stored in my files for identification purposes only and will not be utilized for any other purposes.
Appointment reminders	• I may use and disclose medical information to remind you of an appointment, if applicable.
Comply with the law	• I will share medical information about you when required to do so by federal or state laws or regulations.
Address workers’ compensation, law enforcement, and other government requests	I 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.
Do research	• I can use or share your information for health research.
Respond to lawsuits and legal actions	• I can share health information about you in response to a court or administrative order, or in response to a subpoena.

MY Responsibilities

• I are required by law to maintain the privacy and security of your protected health information.
• I will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• I must follow the duties and privacy practices described in this notice and give you a copy of it.
• I will not use or share your information other than as described here unless you tell me I can in writing. You may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.