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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.



The law protects the privacy of the health information we create and obtain in providing care and services to you. For example, your protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information related to these services. Federal and state laws allow us to use and disclose your protected health information for purposes of treatment, payment, and health care operations.



For Treatment: Information obtained by a licensed provider or other member of our healthcare team will be recorded in your medical record and used to help decide what care may be right for you. For example, your physician may need to consult with specialists about your care. Information about you would be shared with other providers to help understand your care needs.


For Payment: When we request payment from your health plan or other payers, they need information from us about your medical care such as diagnoses, procedures performed, or recommended care in order to cover the services provided to you. For example, we may need to give your health plan information about your therapy you received so your health plan will pay us or reimburse you for the procedure. We will not disclose your health information to third party payers without your authorization unless allowed to do so by law.


For Health Care Operations: We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to make sure that all of our patients receive quality care. For example:

• We may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you.

• We may disclose information to physicians, student clinicians, medical assistants, technicians, or other clinic personnel for review and learning purposes.

• We may use and disclose your information to conduct or arrange for services, including medical quality reviews; accounting, legal, risk management and insurance services; and audit functions, including fraud and abuse detection and compliance programs.



Clinic Directory: Unless you notify us that you object, we may use your name, location in the facility, and general condition for directory purposes. Directory information may be provided to people who ask about you by name. This information also includes your appointment dates. No medical information, including your chief complaint or the nature of your care, will be disclosed as part of directory information.


Communication with Family and Friends: We may release medical information about you to a family member or friend who is involved in your care and/or helps pay for your care. We may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.


As Required By Law: We will disclose medical information about you when required to do so by federal, state, or local law.


To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to prevent the threat.



Right to this Notice: You have a right to a paper copy of this notice. You may ask us to give you a copy at any time.


Right to Inspect and Copy: You have a right to inspect and receive a copy of certain health care information including certain medical and billing records. To obtain a copy of your records you must submit your request in writing on an official authorization form to ASA Acupuncture & Oriental Medicine. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. If you would like to schedule an appointment to view your record or if you have any questions about your right to inspect and copy your record.

Note: We are required to retain our records of the care that we provided to you. Although you have the right to exercise control over certain uses and disclosures of your medical information, the medical record maintains on your care is property of ASA Acupuncture & Oriental Medicine may deny your request to inspect and copy in certain limited circumstances. If you are denied access to your medical record, you may request that the denial be reviewed. We will comply with the outcome of the review.


Right to Request Amendment: You have a right to ask that your health information be amended by sending a written request. We have the right to deny this request under certain circumstances. You may write a statement of disagreement if your request is denied. This statement of disagreement will be stored in your medical record, and included with any release of your records.


Right to a List of Disclosures: You have the right to request a list of disclosures. This is a record of certain disclosures we made of medical information about you in accordance with applicable laws.

You must submit your request in writing to our to obtain a list of disclosures. The first time you request a list within a 12 month period will be free of charge. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.


Right to Request Restriction: You have a right to ask us to restrict certain uses and disclosures of your health information. You may be asked to make this request in writing. Ask your caregiver if you have questions about this. We will comply with all reasonable requests.


Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a specific way or location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you may be asked to make your request in writing. Ask the person (or department) that gave you this notice for more information about this process. We will comply with all reasonable requests. Your request must specify how or where you wish to be contacted.


Right to Revoke Authorization: Other uses and disclosures of your health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us with permission to use or disclose health information about you under these circumstances, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and information disclosed to other party’s may no longer be afforded certain protections under the law once released and might be re-disclosed to other parties without your authorization.


Changes to this Notice: We reserve the right to change this notice at any time. Any revised or changed notice will be effective for medical information we already have about you as well as any information we receive in the future.


Complaints: If you believe your privacy rights have been violated, you may contact ASA Acupuncture & Oriental Medicine. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. The quality of your care will not be jeopardized nor will you be penalized for filing a complaint.

ASA Acupuncture & Oriental Medicine records health care services we provide you. You may ask to see and copy of your record. You may ask to correct the record. We will not disclose your record to others unless you direct us to do so, or unless the law authorizes or compels us to do so.

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