You can download the following forms and bring them in completed to your first appointment.
A copy of each of these forms is available to you by request.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE READ IT CAREFULLY.
If you have any questions about this notice, please contact Santee Acupuncture (619) 354-9570.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
The following categories describe different ways that health information about you may be used or disclosed. Unless otherwise noted, each of these uses and disclosures may be made without your permission. For each category of use or disclosure, an explanation with examples is provided. Not every use or disclosure in a category is listed. However, unless asked for a separate authorization, all of the ways permissible to use and disclose information will fall within one of the categories.
For treatment: Your health information may be used to provide you with healthcare treatment and services. Your health information may be disclosed to doctors, nurses, technicians, health students, or other personnel who are involved in taking care of you. They may work at this office or at another medical office, lab, pharmacy, or other healthcare provider to whom we may refer you for consultation, to perform medical investigations, or for other treatment purposes. For example, a doctor treating you may need to know if you are on any herbs that may interfere with a specific drug so we may provide that information to a physician treating you at another institution.
For payment: Health information about you may be used and disclosed so that the treatment and services you receive may be billed to and payment collected from you, an insurace company, a state Medicaid agency, or a third party. For example, it may be necessary to give your health insurance plan information about your office visit so your health plan will pay the provider or reimburse you for the visit. Alternatively, a state Medicaid agency may require the information so that the provider may be reimbursed for services provided to you. In some instances, your health plan provider may need to know about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For health care operations: Health information about you may be used and disclosed for operations of healthcare practice. These uses and disclosures are necessary to run the practice and make sure that all patients receive quality care. For example, health information may be used to review treatment and services and evaluate staff performance in caring for you. Health information about many patients may also be combined to decide what additional services should be offered, which are unnecessary, whether certain new treatments are effective, or to compare performance and see where we can make improvements. Identifying information may be removed from this set of health information so others may use it to study healthcare delivery without learning who our specific patients are.
Research There may be situations where your information is used for research purposes. For example, a research project may involve comparing efficacy of one medical treatment over another. For any research project that uses your health information, authorization from you will be obtained or an Institutional Review or Privacy Board will be asked to waive the requirements to obtain authorization. A waiver of authorization will be based upon assurances from a review board that the researchers will adequately protect your health information.
As required by law: When required by federal, state, or local law, your health information will be disclosed.
To avert a serious threat to health or safety: When necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person, your health information may be disclosed. Any disclosure, however, would only be to someone able to help prevent the threat.
Worker’s compensation: Your health information may be released for Worker’s Compensation or similar programs, These programs provide benefits for work-related injuries or illness.
Public health risks: Public health activities may require the disclosure of your health information. Such activities generally include the following:
Health oversight activities: Your health information may be disclosed to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and disputes: If you are involved in a lawsuit or dispute, your health information may be disclosed in response to an order issued by a court or administrative tribunal, or in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only after efforts have been made to inform you about the request and you have time to obtain an order protecting the information requested.
Law enforcement: If asked to do so by a law enforcement official, your health information may be released: