Hippa Notice "Privacy Disclosure and Policies"
As a patient at this clinic, you have the right to know how your private, confidential healthcare and personal information is being protected. Below are the methods in which your information is secured confidentially in accordance with the Health Insurance Portability and Accountability Act of1996 (HIPPA). This notice describes the policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected.
Safeguards in place include:
· Limited access to facilities where information is stored.
· Policies and procedures for handling information.
· Requirements for third parties to contractually comply with privacy laws.
· All medical files and records (including email, regular mail, telephone, and faxes sent) are kept on permanent file.
Should we see you socially, by coincidence or intent, we will not acknowledge how we are acquainted unless you infer consent through introduction, etc. It is our preference to discuss your health in the office setting only to protect you privacy and ensure that important information is kept in your chart.
We consult with other healthcare practitioners and clinical specialists while working on patient cases and treatment plans. These conversations and transfers of information by phone, in person, by fax, or email are confidential, and names are not used unless necessary and consent is provided from you either verbally or in writing. In administering your health care, we may gather and maintain information that may include these examples of non-public personal information
· From your medical history, treatment notes, all test results, and any letters, faxes, emails or telephone conversations to or from other health care practitioners.
· From health care providers, insurance companies, workman’s comp and your employer, and other third party administrators (e.g. requests for medical records, claim payment information)
Your confidential healthcare information is private and cannot be copied and shared with anyone else without your written, signed consent. In some cases, if time does not permit, your verbal approval may be accepted after proper identification is acquired. Copies of released records are sent by mail or fax, and are accompanied by a Confidential Patient Information Cover Sheet if faxed.
Definition and Penalties to Comply
Protected health information is any information, whether oral or recorded, in any form or medium that: 1) is created or received by a healthcare provider, health plan, public health authority, employer, life insurer, school or university, or healthcare clearing house in the normal course of business, and 2) relates to the past, present, or future physical or mental health or condition of an individual; the provision of healthcare to an individual; or the past, present, or future payment for the provision of healthcare to an individual. This information may reside in any medium: tape, paper, disc, fax, email, and/or digital voice message.
I have read and understand my right to privacy, as stated above, and agree to have Heidi Cameron, Licensed Acupuncturist maintain my records confidentially in accordance with the law. I agree to inform Heidi Cameron, Licensed Acupuncturist if I need any special arrangements pertaining to this issue.
Cameron Acupuncture request payment for your treatment at the time of service.
Payment for Treatment
Is due in cash, check, or credit/debit card when you arrive for your appointment after your treatment. Please make checks payable to Cameron Acupuncture.
At times, Cameron Acupuncture uses email to correspond with patients as a convenience. However, these emails are not encrypted and could theoretically be read by an outside party with the technical skills to intercept such correspondences. By initialing this section, you consent to allow Cameron Acupuncture to correspond with you via email despite these potential risks.
24 Hour Advance Notice
Is required when cancelling any appointment. This allows the opportunity for someone else to schedule an appointment. If you are unable to give 24 hours advance notice, you will be charged $35. This amount must be paid prior to your next appointment. If appointments were purchased in a package and you fail to provide 24 hours advance notice, you will also be charged $35, which must be paid at or before the time of your next scheduled prepaid appointment.
You will be considered a “no-show” if you miss an appointment for any reason and did not cancel it at least 24 hours in advance. You will be charged the full service fee for your missed appointment. This amount must be paid prior to your next appointment. If appointments were purchased in a package, then the missed, cancelled or rescheduled appointment will be deducted from the number of remaining appointments in that package.
I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my practitioner. I have stated my pertinent medical conditions, and will update the practitioner of any changes in my health status.
I understand that my failure to do so may pose a threat to my health and/physical well being and I hold harmless Integrative Health Chinese Medicine Centre and my practitioner from any liability whatsoever arising from failure on my part.
Informed Consent to Treatment:
By signing below, I do hereby request and voluntarily consent to the performance of acupuncture treatments and other procedures within the scope of practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist named above and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed above or any other office or clinic, whether signatories to this form or not.
I understand that methods of treatment may include, but are not limited to, acupuncture, cupping, electrical stimulation, Tui-Na (Chinese massage), moxabustion (Moxa), Chinese herbal medicine, nutritional counseling and lifestyle coaching.
Acupuncture: This is a safe treatment involving the insertion of fine sterile and single use needles through the skin. Treatments can occasionally produce a mild but temporary discomfort, usually achiness, tingling or soreness at the acupuncture site. Treatments can also cause slight bleeding and may leave a non-painful bruise at the acupuncture site. Other possible risks from acupuncture include dizziness and fainting. I agree to come to each session having eaten within the past 3 hours, and I will report to my Licensed Acupuncturist any dizziness or light-headedness that occurs during or after an acupuncture treatment. Extremely rare risks of acupuncture include nerve damage, organ puncture and infection. These risks have an extremely low incidence, especially when acupuncture is administered properly by a Licensed Acupuncturist. Traditional Chinese Herbal Medicine Treatments: Chinese herbs have been used safely for centuries. Infrequently, one may experience digestive upset or other reactions to herbs. If I experience any discomforts related to the use of any herbs I am prescribed, I understand that I should stop the herbs and that I am responsible for informing my Licensed Acupuncturist of my symptoms. Some herbs may be inappropriate during pregnancy or breastfeeding. I accept full responsibility to inform my practitioner immediately if I am pregnant or breastfeeding, or if I am attempting or suspecting pregnancy. With all herbal treatment, I agree to follow the prescribed dosage and administration guidelines given to me by my acupuncturist. I will inform my practitioner if I am taking any medications, or if there are any changes in my medications, before any herbal treatment is initiated.
Heat Treatments with Moxa or a TDP Lamp: These methods are used to warm areas of the body to promote health. Every precaution is taken to prevent over-warming, but the rare possibility of mild burns exists.
Cupping: This technique involves a localized suction produced by heating a small glass cup. There is a possibility of local non-painful bruising from this suction. Very rarely a slight burn or blister may appear due to the heat.
Gua Sha: Gua Sha is light scraping on the skin in a small area using a smooth-edged instrument. This often results in bruising of the treated area. The bruising, which is not painful, usually resolves in 3-7 days.
Electro-Acupuncture: A mild electric micro-current similar to a TENS treatment may be used to stimulate the acupuncture points. A mild tingling or tapping sensation will be felt during treatments. Occasionally a mild achiness or soreness will be felt at the areas treated for up to a day after the treatment. I understand that I must inform my practitioner if I am using a pace maker or have any heart or neurological condition prior to having this treatment.
Acupressure and Massage: Acupressure and massage are used to reduce or prevent pain, and to normalize the body’s physiological functions. I will inform my Licensed Acupuncturist of any areas of injury or extreme discomfort, as well as any areas where I have had surgery, prior to any massage. I understand that there may be muscle soreness or achiness as well as the possible aggravation of symptoms existing prior to the treatment during or after massage.
I understand the clinical and administrative staff may review my patient records and lab records but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, 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 conditions and for any future condition(s) for which I seek treatment.
Patients who are pregnant, have a pacemaker or heart condition, have a seizure disorder, or those with a bleeding disorder or taking blood thinners should notify and discuss this with the acupuncturist before proceeding with acupuncture.
I understand that there may be other treatment alternatives, including treatment offered by a licensed physician, as Heidi Cameron, L.Ac is not a primary care physician.
By voluntarily signing below I acknowledge that I have read and understand all of the above information. I understand that I may ask my practitioner for a more detailed explanation. I give my permission and consent to treatment.*