As your health care provider, we use your health information for evaluation and treatment; as well as to obtain payment for treatment. If you are referred to another health care provider, or at your request, your medical records may be shared with those providers. We may use your health care information without your authorization for the following reasons:

• Public health safety
• Auditing purposes
• Emergencies
• At the request of your insurance carrier
• When required by law

In all other circumstances, we will ask your written permission to release your medical information in the form of a “Release of Medical Records” form. If you choose to sign such a form, you have the right to revoke that authorization at any time. If you would like to review our “Notice of Privacy Practices,” please request a copy at the front desk. If, at any time, we change our policies regarding your medical information, you will be informed with a new “Privacy Practices” form to sign, as well as a new copy of “Notice of Privacy Practices.”

You have the right to view and obtain a copy of your medical record. You also have the right to know to whom we have disclosed your medical records. If you believe the information in your medical record is not correct or missing information, you have the right to request that such information is corrected or added to your medical record.

If you have any questions or concerns about your medical records, please contact Whole Health Center, or you can file a written complaint with the U.S. Department of Health and Human Services. Whole Health Center is required by law to protect your medical information and provide this notice to you, along with your signature acknowledging your receipt of this information.

Whole Health Center reserves the right to change the privacy practices that are described in the “Notice of Privacy Practices.” You may obtain a revised “Notice of Privacy Practices” by notifying the office of Whole Health Center and requesting a revised copy. Our office sends thank you cards for referrals, periodic newsletters, and participates in other non-private contact. This may be via email or postal service. Reminders of your appointments may be via email or telephone.

Consent

I understand that I have a right to read the “Notice of Privacy Practices”. The “Notice of Privacy Practices” describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills, or in the performance of health care operations at Whole Health Center. This “Notice of Privacy Practices” also describes my rights, as well as the duties of the practitioner with respect to my protected health information.

I consent to the use or disclosure of my protected health information by Whole Health Center for the purpose of analyzing, diagnosing, or providing treatment; as well as obtaining payment for my health care bills or to conduct health care operations. I understand that analysis and treatment by Acupuncture Associates may be conditioned upon my consent as evidenced by my signature below.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or healthcare operations of the practice. Whole Health Center is not required to agree to the restrictions that I may request. However, if Whole Health Center agrees to a restriction that I request, the restriction is binding on Whole Health Center. I have the right to revoke this Consent, in writing, at any time, except to the extent that Whole Health Center has taken action in reliance on this Consent.

My “protected health information” means health information, including any demographic information collected from me and created or received by my physician, another health care provider, a health plan, my employer, or a healthcare clearinghouse. This protected health information relates to my past, present, or future physical or mental health or condition that identifies me, or there is a reasonable basis to believe the information may identify me.