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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 (Reiki, Healing
Touch™,
TAT®, BodyTalk Access™), 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. I am qualified to use ABC
codes regarding your treatment information. 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.
Should a family member contact this office, I request the following:
 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.
Do
NOT inform them that I have received services from
Compassion’s Doorway.
Provide
answers
to billing-related questions.
Do
NOT provide answers to billing-related questions.
Print Patient Name:
____________________________________________________________________
Relationship to Patient:
_________________________________________________________________
Signature:
___________________________________________________________________________
Date:
_______________________________________________________________________________
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:
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.
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