Health Insurance Portability & Accountability Act (HIPAA)

HIPAA Privacy Notice

Typically, your medical record contains your treatment plan, health history, physical findings, information that you provide to us, and billing records. This record serves as:

The basis for planning your treatment.
A means of communication between our acupuncturists, staff, and any healthcare providers that you authorize us to share information with.
A tool for assessing and continually improving the quality of care provided by Verdae LLC doing business as Verdae Wellness.

Your Rights Regarding Your Health Information

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

Get an Electronic or Paper Copy of Your Medical Record

You can ask to see or obtain an electronic or paper copy of your medical record and other health information that we maintain about you. Ask us how to do this.
We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask Us to Correct Your Medical Record

You may ask us to correct health information about you that you believe is incorrect or incomplete. Ask us how to do this.
We may deny your request, but we will explain our reason in writing within 60 days.

Request Confidential Communications

You can request that we contact you in a specific way (for example, by home phone, office phone, or email) or send mail to a different address.
We will agree to all reasonable requests.

Ask Us to Limit What We Use or Share

You may ask us not to use or share certain health information for treatment, payment, or healthcare operations. We are not required to agree to your request and may decline if it would affect your care.
If you pay for a service or healthcare item out-of-pocket in full, you may request that we not share that information with your health insurer for payment or operations purposes. We will agree unless a law requires us to share that information.

Get a List of Those With Whom We’ve Shared Information

You may request a list (accounting) of the times we have shared your health information for six years prior to the date of your request, including who we shared it with and why.
This list will exclude disclosures related to treatment, payment, and healthcare operations, as well as certain other disclosures (such as those you requested).
One accounting per year will be provided free of charge. Additional requests within a 12-month period may incur a reasonable, cost-based fee.

Get a Copy of This Privacy Notice

You may request a paper copy of this notice at any time, even if you agreed to receive it electronically. We will provide it promptly.

Choose Someone to Act for You

If you have granted someone medical power of attorney or if someone is your legal guardian, that person may exercise your rights and make healthcare decisions on your behalf.
We will verify the authority of that person before allowing them to act for you.

Your Choices for How We Share Information

For certain health information, you may tell us your preferences regarding what we share. If you have a clear preference for how we share your information in the situations described below, please inform us and we will follow your instructions.

In these situations, you have the right to tell us to:

Share information with your family, close friends, or others involved in your care.
Share information in disaster relief situations.

If you are unable to communicate your preference, we may share your information if we believe it is in your best interest. We may also share your information when necessary to prevent a serious and imminent threat to health or safety.

We will only use or share your information for marketing purposes if you provide written permission.

Fundraising Communications

Verdae LLC doing business as Verdae Wellness may contact you for fundraising purposes. If you prefer not to receive these communications, you may request that we stop contacting you for fundraising.

OUR USES & DISCLOSURES

How We Typically Use or Share Your Health Information

We typically use or share your health information in the following ways:

Treatment

We may use your health information and share it with other healthcare professionals who are involved in your treatment.

Practice Operations

We may use and share your health information to operate our practice, improve patient care, and contact you when necessary.

Payment

We may use and share your health information to bill and receive payment from you or another responsible party.

Identity Verification

We may request certain information to verify your identity. Identification methods may include photographs, fingerprints, or other biometric data.

This information is stored solely for identification purposes and will not be used for any other purpose.

Appointment Reminders

We may use or disclose medical information to contact you with appointment reminders.

Legal Requirements

We will disclose your medical information when required by federal or state laws or regulations.

Government Requests

We may share health information for:

Workers’ compensation claims
Law enforcement purposes
Health oversight agency activities authorized by law
Approved health research

Legal Proceedings

We may share health information in response to a court order, subpoena, or administrative request.

Our Responsibilities

Verdae LLC doing business as Verdae Wellness is required by law to:

Maintain the privacy and security of your protected health information.
Notify you promptly if a breach occurs that may compromise the privacy or security of your information.
Follow the privacy practices described in this notice.
Provide you with a copy of this notice.

We will not use or share your information other than as described here unless you give us written permission. If you grant permission, you may change your mind at any time by notifying us in writing.

For more information about HIPAA privacy rights, visit:
https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

CONSENT

By voluntarily signing this form, I acknowledge that:

I have read or had read to me this consent and privacy notice.
I have been informed about the potential risks and benefits of acupuncture and related procedures.
I have had the opportunity to ask questions.
I agree to the clinic’s cancellation policy.
I understand my privacy rights as outlined above.

I consent to the recommended care for myself or my child.

This consent applies to the entire course of treatment for my current condition and for any future condition(s) for which I or my child may seek treatment from Verdae LLC doing business as Verdae Wellness.