TAKAZAWA ACUPUNCTURE, PLLC PRIVACY NOTICE SUMMARY

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED

 

The first page of this notice provides a summary of the content within.
Please refer to the full notice for a complete description of our privacy practices.

 

     A Federal law called the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) creates new rights for patients. Among other things, HIPAA grants you the right to obtain a copy of this Privacy Notice. We are required to ask that you sign a document stating that you received a copy of the Notice.

       You may review the Privacy Notice now or at a later time. At some point, you should read it carefully, because it explains: (1) generally, how we use health care information about you; (2) that we, like other health care providers, may use and disclose health information about you without express permission as part of your treatment, to arrange for payment for health care services, and for our internal operations; (3) other circumstances where we may use or disclose health-related information about you (with or without your permission); and (4) the rights you have with respect to your health information, namely:

            a.         Your right to receive a copy of this Privacy Notice;

            b.         Your right to inspect and copy certain health information;

            c.         Your right to receive an accounting of certain disclosures that we make of your health information;

            d.         Your right to request restrictions on how we Use and Disclose your health information;

            e.         Your right to request that we communicate with you at alternative locations, mailing addresses or telephone numbers;

            f.          Your right to request amendments to your health information;

            g.         Your right to revoke an authorization that we obtained to disclose your health information; and

            h.         Your right to complain about suspected violations of your privacy rights.

 

            At TAKAZAWA ACUPUNCTURE, PLLC we take confidentiality seriously. We encourage you to read this notice and keep a copy of this notice for your records.

 

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THE POLICIES IN THIS NOTICE BECOME EFFECTIVE ON September 19, 2017

 

 

I have read and understand the above content.  All of my questions have been answered satisfactorily.

 

 

______________________________

Patient

 

 

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Witness

 

 

Dated:

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