Hippa Consent Form

Acupuncture & Homeopathy of Hingham

195 Whiting Street, Hingham, MA 02043
781-749-8088

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your health information is important to us.

The Health Insurance Portability & Accountability Act (HIPPA) is a federal program that requires all medical records and all health information used or disclosed by us in any form, whether electronically or on paper, be kept confidential. We are also required to give you this notice about our privacy practices, our legal duties and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect.

Uses and Disclosures of Health Information
We may use and disclose health information about you for treatment, payment, and healthcare operations.

Treatment means providing, coordinating or managing health care and related services by one or more health care providers

Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities and utilization review.

Healthcare operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. We may create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses 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.

Patient Rights:

You have the following rights with respect to your Personal Health Information (PHI):

You have the right to inspect and copy your PHI.

You have the right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures of PHI, including those related to disclosures to family member, other relatives, close personal friends, or any other person identified by you.  We are, however, not required to agree to requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

You have the right to reasonable requests to receive confidential communications of PHI from us by alternative means or at alternative locations.

You have a right to receive an accounting of disclosures of PHI.

If you receive this notice on our website or by electronic mail, you are entitled to obtain a paper copy of this notice upon request.

We reserve the right to change the terms of our Privacy Practices and to make the new notice provisions effective for all PHI that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that we have violated your privacy rights. You have the right to file written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office.  We will not retaliate against you for filing a complaint.

Questions or complaints about privacy practices should be directed to Megan Stewart at Acupuncture & Homeopathy of Hingham.  If you are not satisfied with the manner in which this practice handles your complaint, you may submit a formal complaint without the risk of penalization to:

Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue SW,  Room 509F
Washington, DC  20201

    You must enter name, email and date below to verify you have read the above HIPPA information.

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195 Whiting Street | Hingham, MA 02043 | 781.749.8088 | megan@acupuncturehingham.com

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