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Jeanine DuBois
Compassion's Doorway

Privacy Policy - HIPAA




NOTICE OF PRIVACY PRACTICES

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.

As a provider of energy work (TAT®, Healing Touch, Reiki, BodyTalk Access™) and educational kinesiology, I am committed to protecting health information about you. I create a record of our interactions and the services that you receive from me for use in your biofield sessions. Typically, this record may contain information regarding your health history, symptoms you may be experiencing, physical health and energy assessment, biofield  intervention, and proposed energy work. This health information will only be utilized to the extent necessary to provide you with quality care.

My Responsibility: I am required by law (Health Insurance Portability & Accountability Act of 1996, termed “HIPAA”) to

  • ensure that health information that identifies you is kept private and confidential.
  • give you this Notice of my legal duties and privacy practices with respect to your health information.
  • follow the terms of this Notice as long as it is in effect. If I revise this notice, I will follow the terms of the revised Notice as long as the revised Notice is in effect.

How I may use or disclose your health information.
  • Treatment/intervention:  The type and amounts of your health information furnished to other health care providers will be limited to relevant and appropriate information needed to provide for your care and treatment.
  • Payment: I may disclose your health information to third party payers, such as your insurance company, Medicare, Medicaid, worker’s compensation, or a flex fund provider to support your reimbursement for services rendered. Since I operate on a cash basis, I will not be obtaining payment from an outside source.
  • Regular health care operations: Although unlikely, I may be required to disclose your health information in order to review my services for purposes of quality assurance, inspection, or audit. I may disclose health information to other health care providers to the extent necessary for them to provide you the appropriate level of care and treatment. To the extent allowed by law, if a family member, other relative, or close personal friend is legally involved in your health care and  the health information is directly relevant to such person’s legal involvement with your care, I may release that health information about you to that individual.
  • To avert a serious threat to health and safety: I may use and disclose health information about you when necessary to prevent a serious threat to the health and safety of you or another person or the general public. Any disclosure would be limited to someone who is able to help prevent the threat.
  • Research: I may disclose your health information to researchers conducting research approved by an institutional review board and  for which you have given informed consent.
  • Judicial, administrative proceedings, or law enforcement activities: If legally required to or at your request, I may disclose your health information in an administrative or judicial proceeding, lawsuit, dispute, or certain law enforcement activities.
  • Public health: As required by law, I may disclose your health information to public health authorities for purposes related to preventing or controlling disease, injury, or disability; reporting child or adult abuse or neglect; reporting domestic violence; reporting disease or infection exposure.
  • Consultation and practitioner development: For purposes of consultation and practitioner education, I may share de-identified health information by removing all references to individually identifiable information.
  • Appointment reminders: Although it is not my standard practice, I may use and disclose health information to contact you as a reminder that you have an appointment with me.
  • Special privacy protections for alcohol and drug abuse information: Alcohol and drug abuse health information has special privacy protections. I will not disclose any information identifying a client as being a patient, or provide any health information relating to a client’s substance abuse treatment unless: (a) the client consents in writing, (b) a court order requires disclosure of the information, (c) health personnel need the information to meet a health emergency, (d) it is necessary to report a crime or a threat to commit a crime, or to report abuse or neglect as required by law.

When I may not use or disclose your health information: Except as described in this Notice of Privacy Practices, I will not use or disclose your health information without your written authorization. If you do authorize me to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. A revocation of authorization will be effective on the date it is received and will not affect previous disclosures.

Your health information rights:
  • Right to request restriction:  You may request restrictions on certain uses and disclosures of your health information. I am not, however, required to agree to a requested restriction. If I do agree, I must abide by it unless you remove the restriction in writing.
  • Right to confidential communications: You may request that I communicate confidential information in a certain way or at a certain location, and you must specify how or where you wish to be contacted.
  • Right to inspect and copy: You have the right to inspect and copy your health information. You may be charged a nominal fee for requested copies of your health information record.
  • Right to request amendment: You have the right to request that I amend your health information that is incorrect or incomplete. Since I am not required to change your health information, if your request is denied, I will provide you with information  as to how you can disagree with the denial.
  • Right to accounting of disclosures: You have the right to request a list of disclosures of your health information made in the past six years but not prior to April 14, 2003, to persons or institutions other than for health care treatment, payment, or operations.
  • Right to a copy of this notice: You may request a paper copy of this Notice of Privacy Practices.

This notice is effective as of April 15, 2003, and I am required to abide by the terms of the Notice of Privacy Practices currently in effect. I reserve the right to amend the terms of my Notice of Privacy Practices and to make the new notice  provisions effective for all protected health information that I maintain. I will post and you may request a written copy of a revised Notice of Privacy Practices.

HIPAA Privacy Policy
If a family member contacts this office, I request the following (put an X for each choice):

Inform them of my presence at this office:
Do NOT inform them of my presence at this office:





Inform them that I have received services from
Compassion’s Doorway / Jeanine DuBois:
Do NOT inform them that I have received services from
Compassion’s Doorway / Jeanine DuBois:





Provide answers to billing-related questions:
Do NOT provide answers to billing-related questions:





HIPAA / Privacy Policy: enter in box to right "Privacy Policy"
*Session Participant's full name and today's date:
*Email address:
Street Address:
*City, State, Zip Code, Country:
*Phone:
Clicking the Agree button below indicates you agree to all statements in this HIPAA / Privacy Policy.

It will send you to a page where you may pay for a session.
If you are a new client, please speak with Jeanine first.

Feel free to include a message to the right.
 
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OFFICE USE ONLY

I attempted to obtain the patient’s signature in acknowledgment of this Notice of Privacy Practices, but was unable to do so as documented below:
Date:

Initials:

Reason:





You have recourse if you feel that your privacy protections have been violated. You have the right to the written complaint with my 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 my office. I will not retaliate against you for filing a complaint.


Please contact me for more information:

Jeanine DuBois
Compassion’s Doorway
Lake Oswego, OR   97035
phone: 503-697-0586
email: jd@compassions-doorway.com               

For more information about HIPAA or to file a complaint:

The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D. C. 20201
(202) 619-0257
Toll Free: 1-877-696-6775




Tapas Acupressure Technique,  TAT, and TATLife are registered trademarks of TAT creator Tapas Fleming, being used with permission.

Brain Gym is a registered trademark of the Educational Kinesiology Foundation / Brain Gym International.


 
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updated 30 March 2011