Merriam Park Acupuncture Intake Forms

Step 1 of 4 - Merriam Park Acupuncture Notice of Privacy Practices

Our clinic is dedicated to providing service with respect and dignity. Protecting your privacy and healthcare information is of utmost important with respect to our relationship. We are required to tell you how we will be keeping your protected information confidential. This notice describes our office’s policy for how medical information is used and disclosed, how you can access your information and how your privacy is protected. Your signature is required on receipt of this information. This notice will remain in effect until it is replaced or amended by changes in law.

We may gather personal information and health information in several ways. Information we receive from you, information we receive from other healthcare providers, information we receive from third party payers.

Your health information may be used for the following purposes:

You should be aware that during the course of our relationship you will likely use and disclose health information about your treatment, payment, and healthcare operations. For the purpose of this notice, “health information” includes everything you disclose to us including your name, address, email address, and telephone number.

We may use your health information to provide, coordinate and manage healthcare treatment or services within this clinic. We may, with your written consent, disclose health information about you to other healthcare professionals who are involved in treating you.

We may use information to receive payment from you, an insurance company or third party for services we provide to you.

We may use health information for certain activities related to business function within this office.

We may use health information to contact you as an appointment reminder, to reschedule an appointment or to contact your regarding your treatment/condition.

With your written consent we may disclose your information, to your family members, personal friend, or any other friend which would directly relate to your health care or payment for such healthcare.

We may disclose or use minimally necessary and legally required health information about you for research purposes.

We may disclose or use minimally necessary health information for other special situations such as public health activities, for averting a serious thereat to health, or safety for workers’ compensation purposes.

We may disclose minimally necessary health information about you when required to do so by federal, state, or local law.

You may specifically authorize us to use protected health information for any purpose, or to disclose our health information about you, by submitting an authorization in writing. Such disclosers will be made to any personal representative you designation to share your personal protected health information.

This office will send you newsletters via email or use telephone calls for the purpose of communication or scheduling.

Patient rights:

Upon written request you have the right to access, review or receive copies of your health care records.

Upon written request you have the right to receive a list of items this office disclosed about your healthcare information.

You have the right to request that this office place additional restrictions on disclosure of your protected health information.

You have the right to request that we amend your protected health information . The request mush be in writing.

If you have questions or complaints or want more information call 651-207-3019. Complaints about your privacy rights or how your privacy is handled at the clinic can be directed to the privacy officer by calling this office or directing a letter to their attention. Dawn Pivec, 1523 Selby Ave., St. Paul, MN 55104

If you are not satisfied with how this office has handled your complaint you may submit a formal complaint to U.S. Department of Health and Human Services, 200 Independent Ave SW, Room 509 F, HHH Building, Washington, DC 20201.