Notice of Privacy Practices, Laurie Mitchell Acupuncture & Oriental Medicine

Legal responsibilities of Laurie Mitchell, Licensed Acupuncturist, as mandated by Federal and State legal requirements, your private health information must

be protected and all policies must be followed by our practice. As part of these regulations, we are required to ensure that you are aware of privacy policies, legal duties and your rights to your protected health information which are outlined below and will be in effect for the duration. We reserve the right to

modify our privacy polices and the terms of this notice at any time and will make such modifications within the guidelines of the law that are effective for all

protected health information that we maintain including protective health information we created or received before the changes were made. A change in the notice will precede all significant modifications. A copy of this notice will be provided upon request. Protected Health Information will be noted as PHI

throughout the remainder of this notice.

PHI USE AND DISCLOSURE

PHI may be used and disclosed for the purpose of treatment, payment and other healthcare operations. Examples cited below further explain the use and

disclosure in writing: Treatment: Use and disclosure of your PHI may be provided to a physician or other healthcare professional authorized in writing (by you) that

is providing treatment to you.

Payment: Your PHI may be used and disclosed to obtain payment for services we provided to you. Healthcare Processes: We may use and disclose your PHI in relations wit our healthcare processes including assessment, improvement

activities, reviewing the competence or qualifications of healthcare professionals, provider performances and evaluating practitioners including

conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: You may provide your authorization in writing at any time for the use and disclosure of your PHI information for any

purpose. You may also choose to revoke your written permission at any time by submitting the revocation in writing. If you revoke your written

authorization it will not affect any use or disclosure prior to the revocation. Your PHI may be used and disclosed to you as described in the Patient Rights section of this notice. In addition, if authorized, your PHI may be used and disclosed to a family member, friend or other person to

the extent necessary to assist you with your healthcare.

Person Involved in Care: In order to accommodate the notification of your location, general condition or death your PHI maybe used or disclosed to a family member, your personal representative or another person responsible for your care. If you are present and wish to object to

such disclosures of your PHI you may do so. If you are incapacitated or if emergency circumstances exist, we will disclose PHI using our

professional judgment, disclosing only PHI that is directly relevant to the person’s involvement in your healthcare. Marketing Health-Related Services: The use of your PHI for the purpose of marketing communications is prohibited without your written

authorization.

Required by Law: Your PHI may be used or disclosed if required by law. PHI disclosure may be made to correctional facilities or law enforcement authorities if requiring custody of such information.

Abuse or neglect: As required by law, if we have reason to believe that you are the victim of possible abuse, neglect or other possible crimes

your PHI maybe disclosed to the appropriate authorities. If we have reason to believe the use or disclosure of your PHI will prevent a serious threat to your health or the health or safety of others we may provide the necessary PHI.

National Security: Under some circumstances, the military may require disclosure of PHI for armed forces personnel. For the purpose of national security activities and counter and lawful intelligence, authorized federal authorities may require the disclosure of PHI.

Appointment Reminders: Your PHI may be used to assist you with appointment reminders in the form of voicemail messages, postcards or

letters. We may also write a thank you card to who ever referred you to our practice.

PATIENT RIGHTS

Access: You have the right to review your PHI and to request photocopies at all times with limited exceptions. You must submit your request in writing using a PHI Access form via the contact information listed at the end of this notice. You will be charged $0.85 per page plus up to $20.00

for staff time to locate and copy your PHI as well as postage costs to mail your PHI if requested. An explanation of itemized fees can be made

available. Disclosure Accounting: Your rights include the choice to receive a review of every time we or our business associates disclosed your PHI for

reasons other than treatment, payment, healthcare information and certain other activities for the last six years. Additional reasonable cost based

fees may be extended if your requests for such information exceed more than once per calendar year. Restrictions: You may request that we apply additional restrictions to any disclosure of your PHI. We are not required to respond to the

application of these additional restrictions. If we agree to follow your request for additional restrictions we will follow the agreement unless an

emergency situation dictates otherwise. Alternative Communications: Your rights include the instruction to request how you are communicated to regarding your PHI. A request in

writing can specify alternate methods or locations regarding your PHI communication. You must identify agreed upon explanations of payment

arrangements under alternative communications. Amendment: You can initiate a written request to amend your PHI. An explanation of why information should be amended must be included.

Be advised that certain conditions may exist where we may reject your request.

Electronic Notice: If you receive a notice electronically, you are entitled to receive the same in writing as well. Questions and Complaints: You have the right to bring the following issues forward at any time:

1. You are concerned that your PHI has not been protected.

2. You believe that an error was made in the decision we made about accessing your PHI. 3. As a result of a response to a request made by you to amend the use or disclosure of your PHI.

4. To have us communicate to you by alternative means or at an alternative location.

Complaints should be made in writing to: The Department of Human Health and Human Services Office for Civil Rights, DHHS 26 Federal Plaza, Suite 3313, New York, NY 10278 on an official complaint form located via the internet at:

http://www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaintform.pdf. Privacy of your PHI is of the utmost importance to us and we are

committed to ensure your privacy at all times. If you file a complaint against us we will not retaliate in any way. We are available to assist you with any questions, concerns or complaints.

HIPAA Compliance Officer, Laurie Mitchell 219 Lake Street, Penn Yan, NY14527

Billiard Square 514 S. Main Street, Canandaigua, NY 14424

Laurie Mitchell Acupuncture & Oriental Medicine Phone:  (315)  729-­‐1785  

www.LMitchellAcupuncture.com  219  Lake  St.  Penn  Yan,  NY  14527  

514  S.  Main  St.  Canandaigua,  NY  14424    

Please  initial  each  section  and  sign  below  as  indicated.    

1. Notice  of  Privacy  Practices:    By  signing  below,  I  acknowledge  receiving  a  copy  of  Laurie  Mitchell’s  Acupuncture  &  Oriental  Medicine  Notice  of  Privacy  Practices.    

Initials:  _______    

2. Insurance  Coverage:  By  signing  below  I  agree  to  pay  the  balance  due  for  services  by  the  provider   in   the   event   that   my   insurance   carrier   does   not   provide   an   Acupuncture  benefit.    

Initials:  _______    

3. Cancellation   and   No   Show   Policy:       In   the   event   that   you   are   unable   to   keep   your  appointment   with   Laurie   Mitchell,   L.   Ac.   you   must   call   24   hours   in   advance   of   the  scheduled   time.     If   you   call   on   the   day   of   your   appointment   or   do   not   show   for   the  appointment,  you  will  be  charged   the   full   cash   rate  amount   for   the  appointment.    No  exceptions  will  be  made.  

Initials:  _______      

Patient  Name:  ____________________________________________        DOB:  _________    

Signature  of  Patient  or  Personal  Representative*:    

________________________________________________________  Date:  __________  

*If  signed  by  a  Personal  Representative  the  following  information  is  required:  

Printed  Name  of  Personal  Representative:  ____________________________________  

Relationship:  ____________________________________  

I. PATIENT ADVISORY TO CONSULT A PHYSICIAN

Acupuncture & Oriental Medicine is committed to your health and well being. We believe that while Oriental Medicine has a great

deal to offer as a health care system, it cannot totally replace the resources available through biomedical physicians. Consequently,

we recommend that you consult your primary care physician regarding any condition(s) for which you are seeking acupuncture

treatment.

We, the undersigned, do affirm that __________________________(patient) has been advised by listed Licensed

Acupuncturist, Laurie Mitchell, to consult a physician regarding the condition(s) for which such patient seeks an acupuncture

treatment.

________________________________ ____ _________________ Patient Signature Date _____________________________________ _________________ Laurie Mitchell, Licensed Acupuncturist Date

II. INFORMED CONSENT FOR ACUPUNCTURE TREATMENT

I, __________________________________, consent to acupuncture treatments and other procedures associated with the practice of traditional Acupuncture & Oriental Medicine provided by Laurie Mitchell. I have discussed the nature and purpose of my treatment with the member of the clinical staff named below. I understand that methods of treatment may include but are not limited to acupuncture, moxibustion, cupping, electrical stimulation, and bodywork therapies such as medical message, Tui Na (Chinese Massage) and Shiatsu.

I have been informed that acupuncture is a safe method of treatment, but that it may have side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and also dizziness or fainting. Bruising is a common side effect of cupping. Rare and unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although this site uses sterile, disposable needles and maintains a clean and safe environment. Burns and or scarring are a potential risk of moxibustion. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (from plant, animal and mineral sources) which may be recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, diarrhea, rashes, hives, and tingling of the tongue. I will notify Laurie Mitchell if I am, or become pregnant. I do not expect Laurie Mitchell to be able to anticipate and explain all possible risks and complications of treatment. I understand that Laurie Mitchell may review my medical records and lab reports, and that portions of my records may be used for treatment purposes only. Otherwise, all of my records will be kept confidential and will not be released to any party without my written consent.

By voluntarily signing below I show that I have read, or have had read to me, this consent to treatment, I have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. To be completed by patient (or patient’s representative if the patient is a minor or is physically or legally incapacitated).

Date Consent Completed

Print Name of Patient

Laurie Mitchell, Licensed Acupuncturist

Signature of Patient or Representative

Print Name of Patient Representative and Relationship