Insurance Portability and Accountability Act, HIPAA (1996)

Please review the following carefully. This notice describes how your protected health information or PHI may be used and disclosed. This notice also describes your rights regarding your PHI. HIPAA requires that all healthcare providers maintain the privacy of your PHI. HIPAA also requires that you are given this notice of our legal duties and privacy practices. All employees of Pine Grove Acupuncture will follow the privacy practices set forth in this notice. We safeguard your PHI by limiting access to where PHI is stored and following these policies and procedures for handling PHI. Pine Grove Acupuncture will not disclose your PHI without your written authorization, except in ways described in this notice. Pine Grove Acupuncture reserves the right to change these practices and make any changes effective for all PHI we maintain. A revised notice will be sent to the address on file.

Understanding your Protected Health Information (PHI)

Every time you visit a healthcare provider a record of the visit is made. This record may contain your symptoms, findings from an examination, test results, diagnosis, treatment and plan for future treatments or care. PHI may also be collected from other providers, during intake, payment and other related operations. HIPAA specifically protects personal data such as name, address, social security number, date of birth and other information that could be used to identify you as the individual patient associated with your PHI.

Your protected health information, PHI, serves:

• to provide a basis to plan your treatment.

• to provide a way to communicate among healthcare professionals who contribute to your care.

• as a legal document that describes the care you received.

• to provide a way you, or a third-party payer, can verify that the services billed for, were provided.

• as a tool for us to continually assess and improve the care and outcomes we provide.

• as a source of data for research and educating health professionals.

• as a source of information for public healthcare.

Understanding how your protected health information, PHI, is used, helps you:

• to ensure the accuracy of records.

• to understand who may access your records, why they may have access to your records.

• make an informed decision when you authorize your personal health information to be disclosed.

Pine Grove Acupuncture may use or disclose your protected health information, PHI, in the following ways without your written permission.

• Treatment: We will use your PHI for treatment. PHI obtained by the practitioner will be used to determine the best course of treatment. PHI will also be used to track your progress.

• Payment: We may use your PHI for payment. If we bill your insurance your personal health information will need to be shared with your insurance company.

• Clinic: We may use your PHI to enhance and refine clinic practices. Staff may use your information to improve the quality of services provided.

• Reminders: We may contact you with appointment reminders.

• Emergency communication: We may need to notify or assist in notifying your family or other person responsible for your care, your location and general condition.

• Communication with personal representative: We may disclose to family, relatives or a person you identify, your PHI relevant to that person’s involvement in your care or payment related to your case.

• Research: We may disclose PHI to researchers under certain circumstances.

• Identification: Coroners, medical examiners and funeral directors may need your PHI by law to carry out their duties.

• Organ/Tissue donation: Organ procurement organizations may need PHI in accordance with the law for the purpose of tissue donation or transplant.

• FDA: Food and Drug Administration, may need personal health information relative to adverse events regarding food, supplements, or products, for the purpose of recall, repair or replacement.

• Workers comp: Workers compensation or similar programs may need PHI to the extent authorized by law.

• Public health: As required by law we may need to disclose PHI to public health or legal authorities charged with preventing, controlling disease, injury or disability.

• Correctional institutions: If you become an inmate of a correctional institution your PHI may be disclosed to the institution when necessary for your health and the health and safety of other individuals.

• Health oversight: Federal law makes provision for your PHI to be released to the appropriate health oversight agency, public health authority or attorney, when a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or public.

• Special Government Functions: At times the government may require us to disclose PHI to assist the government perform functions related to you. Example: those in the armed services may need their PHI shared with the appropriate military authorities.

• Abuse/Neglect: Suspicion of abuse or neglect may require us to disclose PHI to the appropriate agencies regarding abuse or neglect of children, elderly or domestic partners.

• Threat to health and Safety: PHI may need to be disclosed when necessary to avert threats to health and safety of public or another person. Disclosure will only be to those we believe have the ability to prevent the threat.

• Legally required: As required by federal, state or local law we will disclose PHI.

Your Rights

The record of your protected health information, PHI, is the physical property of the practitioner or facility that recorded it. However, the information contained in that record belongs to you, the patient.

You have the right to:

• request certain uses and disclosures of your PHI be restricted.

• obtain a physical copy of this Notice of Privacy Practices upon request.

• inspect and/or obtain a copy of the record of your PHI.

• request that the record of your PHI be amended under certain circumstances.

• obtain and accounting of disclosures of your PHI.

• request communication of your PHI health information by alternative means or at alternative locations.

• revoke your authorization to use or disclose your PHI, except where we are authorized by law.

Your rights regarding your protected health information:

• Right to request restrictions on use or disclosure of your PHI.

• Right to receive confidential communications.

• Right to inspect and copy your PHI.

• Right to request amendment of your PHI.

• Right to receive and accounting of disclosures of your PHI.

Pine Grove Acupuncture's responsibilities are to:

• maintain the privacy of your PHI.

• provide you with notice of our legal duties and privacy practice (this notice) regarding the information we collect and maintain.

• abide by the terms of this notice.

• notify you if there is a security breach involving your personal health information.

• notify you if we are unable to agree to a requested restriction.

• accommodate reasonable requests you may have to communicate your personal health information by alternate means or location.

If you have questions or would like more information, please ask us for assistance. If you would like to voice your concerns, please contact Pine Grove Acupuncture at PO Box 11380, Prescott, AZ 86304.

Reporting a Problem

If you believe your privacy rights have been violated, you may file a complaint with the US Department of Health and Human Services. A complaint must be filed within 180 days of when you knew or should have known that the violation occurred. More information on how to file a complaint can be found at: https://ocrportal.hhs.gov/ocr/smartscreen/main.jsfhttps://ocrportal.hhs.gov/ocr/smartscreen/main.jsf. There is no retaliation for filing a complaint.

US Department of Health and Human Services (Main Address)

200 Independence Ave. SW,

Washington, DC 20201