THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA)
HIPAA is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

OUR PLEDGE REGARDING YOUR MEDICAL INFORMATION
We respect our legal obligation to keep health information that identifies you private. As obligated by law, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We do not use your health information in our office or disclose it outside of our office without your written permission. In some limited situation, the law requires us to disclose your health information without either a written or verbal consent.

Use and Disclosure With Consent
We will ask you to sign a consent form allowing us to use and disclose your health information for purposes of treatment, payment and healthcare operations in this office. We are allowed to refuse to treat you if you do not sign the consent form.

We are permitted to use and disclose your healthcare records for the purpose of treatment, payment, and healthcare operations. Treatment means providing coordination, or managing healthcare related services by one or more healthcare providers. For example, we may need to share information with other providers or specialists involved in your care.

Payment means activities as obtaining reimbursement for services, verifying coverage, billing or collection activities and utilization review. For example, we disclose treatment information when billing a medical plan for your physical therapy services.

Healthcare operations include the business aspects of running our practice. For example, patient information may be used for training purposes or quality assessment.

Unless you request otherwise, we may use or disclose health information to the extent necessary to help with your healthcare or with payment for your healthcare. In addition, we may use your confidential information to remind you of your appointments by leaving messages at home and/or work. We may send email to the address you provide, send newsletters, birthday cards, thank you notes and other information about our services. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

Use and Disclosure without Consent
In some limited situations, the law requires us to use and disclose your health information without your permission. These examples may never come up at our office at all, but such disclosures are: When a state or federal law mandates that certain health information be reported for a specific purpose. For public health purposes, such as contagious disease reporting and notices to and from the FDA regarding drugs and medical devices. Disclosure to government authorities about victims of suspected abuse, neglect or domestic violence. Uses and disclosures for health oversight activities, such as for the audits by Medicare, or for investigation of possible violations of healthcare laws. Disclosures in response to subpoenas or orders of the court. Disclosures for law enforcement purposes, such as to provide information about someone who is suspected to be a victim of a crime, or to provide information about a crime at our office. Disclosure related to worker's compensation programs.

Your Rights Regarding Your Health Information
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer: The right to request restrictions on certain uses and disclosures of protected health information, including those related to the disclosure of family members, other relatives, close personal friends, or any other person identified by you. We are however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. The right to ask us to communicate to you in a confidential way, such as by phoning you at work rather than at home or by mailing health information to a different address. Please provide a written request. The right to ask to see or to get photocopies of your health information. You may have to pay for photocopies in advance. We do charge a fee to release your records to an outside source other than a healthcare provider (examples are lawyer, healthcare research firm, etc). Please complete our written records request for billing or medical record release. The right to receive an accounting of disclosures of protected health information. The right to amend your protected health information. The right to obtain a paper copy of this notice from us upon request.

This notice is effective as of March 17 th , 2003, and we are required to abide by the terms of Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of the revised Notice of Privacy Practices from this office.

You have the right to file a formal, written complaint with us at the address below, or with the Department of Health and Human Services, Office of Civil Rights, in the event you feel that your privacy rights have been violated. We will not retaliate against you for filing a complaint.

For more information about our privacy practices: For more information on HIPAA or to file a complaint:
Privacy Officer
Alpine Acupuncture
5825 221 ST place SE Suite 204
Issaquah, WA 98027

The US Dept of Health and Human Services Office of Civil Rights
200 Independence Ave. SW Washington DC 20201
(415)-391-7777 877-696-6775 (toll free)
This notice has been issued and considered effective for one year from the date signed.

Signature of Patient or Legal Representative
Date