NOTICE OF PATIENT PRIVACY PRACTICES

The Health Insurance Portability and Accountability Act (HIPAA) revised: 2013

This notice describes how your medical information may be used and disclosed and how you may gain access to this information

Valley Health Acupuncture (VHA) will ask you to sign an Acknowledgment that you have received this Notice of VHA Patient Privacy Practices. In accordance with the HIPAA Privacy Regulation, this Notice describes how VHA may use and disclose your protected health information to carry out treatment, payment of health care operations and for other purposes that are permitted or required by law. The Notice also describes your rights and VHA requirements to protect your health information.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION:

For Treatment. We may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.

For Payment. We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment.

For Health Care Operations. We may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the obstetrical or gynecological care you receive is of the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.

Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose Health Information to contact you to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

Research. Under certain circumstances, we may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Health Information.

SPECIAL SITUATIONS:

As Required by Law. We will disclose Health Information when required to do so by international, federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.

Business Associates. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

Workers Compensation. We may release Health Information for workers compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose Health Information 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.

Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the persons agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.

National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.

Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.

USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that persons involvement in your health care., If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

Disaster Relief. We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES

The following uses and disclosures of your Protected Health Information will be made only with your written authorization:

1. Uses and disclosures of Protected Health Information for marketing purposes; and

2. Disclosures that constitute a sale of your Protected Health Information

Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.

YOUR RIGHTS:

You have the following rights regarding Health Information we have about you:

Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to Valley Health Acupuncture 220 5th Ave SW, Albany OR 97321. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.

Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.

Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to Valley Health Acupuncture 220 5th Ave SW, Albany OR 97321.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, toValley Health Acupuncture 220 5th Ave SW, Albany OR 97321.

Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, toValley Health Acupuncture 220 5th Ave SW, Albany OR 97321. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us out-of-pocket in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to Valley Health Acupuncture 220 5th Ave SW, Albany OR 97321. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our web site, www.http://valleyhealthclinic.com/new-patients.

CHANGES TO THIS NOTICE:

We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page, in the top right-hand corner.

 

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Thank you for chooising us as your health care providers. We are committed to the success of your treatment.

The following is information about our, Finacial Policies, Informed Consent to Treat, and Notice of Patient Privacy Practices.

You will also be asked to fill out your Contact and Insurance Information as well as sign up for our New Patient Education Email Series


Review Privacy Policy

FINANCIAL POLICIES & CANCELLATION POLICY

Valley Health Acupuncture, LLC – Financial Responsibility Agreement

Your insurance policy is a contract between you and your insurance company. Valley Health Acupuncture, LLC is not a party to that contract.

If coverage cannot be verified before treatment, you agree to pay the time-of-service rate for each visit until verification is obtained. Any adjustments after claims are processed will be applied to your account.

If we do not accept assignment of benefits from your insurer, you agree to pay the time-of-service fee and seek reimbursement directly from your insurance if you choose.

By signing this waiver, you authorize Valley Health Acupuncture, LLC to bill your insurance, assign benefits directly to the clinic, and release information necessary to process your claims.

If you arrive more than 15 minutes late and cannot be seen, the visit may be treated as a missed appointment and the missed appointment fee may apply.

I have read, understand, and agree to the Financial Policies of Valley Health Acupuncture, LLC.

December 7, 2025

 

INFORMED CONSENT TO TREAT

Valley Health Acupuncture, LLC – Informed Consent for Acupuncture and Related Therapies

As a patient, you have the right to be informed about your condition and recommended treatment so you can make an informed decision to receive or refuse care.

Providers and Scope of Care

I request and consent to evaluation and treatment by Willard Sheppy, L.Ac., and any other licensed health care provider working with or on behalf of Valley Health Acupuncture, LLC.

I understand that my care may include, but is not limited to, the following therapies within the legal scope of acupuncture and East Asian medicine in this state:

  • Acupuncture with sterile, single-use needles
  • Electro-acupuncture / electrical stimulation
  • Moxibustion (moxa)
  • Cupping
  • Gua Sha
  • Tuina / acupressure / manual therapy
  • Dietary and lifestyle recommendations based on Chinese medical theory
  • Herbal medicine and nutritional supplements (teas, powders, tinctures, capsules, plasters, topicals), which may include plant, mineral, and some animal-derived products

I understand that acupuncture and East Asian medicine are not a substitute for emergency care or primary medical care and that I should maintain a relationship with a primary care provider.

Potential Benefits

I understand that potential benefits may include reduction of pain and other symptoms, improved function and mobility, support for recovery, and improved overall wellness, but that no specific outcome or cure is guaranteed.

Potential Risks & Side Effects

Acupuncture
Minor bleeding or bruising, local soreness, numbness or tingling, temporary worsening of symptoms, dizziness or fainting.

Rare risks include infection, nerve injury, organ puncture (including pneumothorax/lung puncture), and miscarriage in pregnancy.

Cupping & Gua Sha
Temporary bruising or skin discoloration, local soreness or tenderness, and rarely blistering or skin irritation.

Moxibustion
Redness or warmth of the skin, risk of burns or blistering, and smoke or odor that may irritate sensitive individuals.

Herbal Medicine & Supplements
Unpleasant taste or odor, digestive upset (nausea, gas, stomachache, vomiting, diarrhea), headache, rash, hives, itching, or other allergic reactions.

Some herbs may be contraindicated during pregnancy, breastfeeding, or with certain medications.

Electro-acupuncture / Electrical Devices
Mild discomfort, tingling, or muscle twitching; rarely, electrical shock or aggravation of pre-existing symptoms.

Manual Therapy / Tuina / Acupressure
Temporary soreness or achiness, temporary increase or change in symptoms.

Special Notices

I understand it is my responsibility to inform my provider if:

  • I am pregnant, planning pregnancy, or suspect pregnancy.
  • I have a bleeding disorder or use blood-thinning medications.
  • I have a pacemaker or other implanted medical/electrical device.
  • I have or have had cancer, major surgery, serious medical or psychiatric conditions, or other significant health issues.


Patient Responsibilities & Understanding

I understand that:

  • Willard Sheppy is not licensed to prescribe controlled substances and will not prescribe or manage narcotic or controlled medications.
  • Nutritional, herbal, and homeopathic substances recommended or provided at this clinic may not be evaluated or approved by the U.S. Food and Drug Administration (FDA) for specific conditions but are commonly used in traditional medical systems.
  • Willard Sheppy is not a psychologist or psychiatrist; any counseling or lifestyle guidance is for health support and is not a substitute for mental health treatment.
  • No guarantee or warranty has been made regarding the results of treatment and outcomes may vary.
  • I may ask questions at any time about my diagnosis, treatment, risks, benefits, and alternatives, and I may withdraw my consent and discontinue treatment at any time, except to the extent that treatment has already been provided.

I have read this Informed Consent to Treat, had the opportunity to ask questions, and consent to acupuncture and related therapies as described above.

December 7, 2025

 

NOTICE OF PATIENT PRIVACY PRACTICES

The Health Insurance Portability and Accountability Act (HIPAA) revised: 2013

This notice describes how your medical information may be used and disclosed and how you may gain access to this information

Valley Health Acupuncture (VHA) will ask you to sign an Acknowledgment that you have received this Notice of VHA Patient Privacy Practices. In accordance with the HIPAA Privacy Regulation, this Notice describes how VHA may use and disclose your protected health information to carry out treatment, payment of health care operations and for other purposes that are permitted or required by law. The Notice also describes your rights and VHA requirements to protect your health information.

December 7, 2025

For More Information or to Report a Problem

If you would like additional information or have questions about our privacy practices, you may contact the Privacy Office at 541-760-9670 or by writing to the Privacy Office at the address above. You may also file a written complaint at this address. If you believe your privacy rights have been violated, you may file a complaint with Valley Health Acupuncture or with the Department of Health and Human Services.

We support your right to protect the privacy of you protected health and financial information. We will not retaliate in any way if choose to file a complaint with us or with the department of Health and Human Services. For more information on HIPAA privacy requirements, HIPAA electronic transactions and code sets regulations and the proposed HIPAA security rules, please visit ACOGs web site, www.acog.org, or call (202) 863-2584.

I Agree
 I undersigned, hereby authorize Valley Health Clinic and its healthcare providers to record audio my appointments for the sole purpose of accurate documentation and charting of my medical care. I understand that these recordings will be used exclusively to ensure precise and thorough record-keeping in accordance with medical standards and will remain confidential, stored securely, and protected under applicable privacy laws, including HIPAA. I acknowledge that these recordings will not be shared with any third parties without my explicit written consent. By signing below, I consent to the use of recording devices during my medical appointments for charting purposes only.

 

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Marital Status:
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Marital Status:
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Marital Status:
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Chief Complaint: *
Date Symptoms Began: *
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Eighth Patients Name
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Marital Status:
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Chief Complaint: *
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Nature of Injury: *
Auto accident
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Ninth Patients Name
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Ninth Patients Information

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Marital Status:
Currently:

Chief Complaint: *
Date Symptoms Began: *
Nature of Injury: *
Auto accident
Personal injury
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Date of accident
Tenth Patients Name
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Date of Birth
Tenth Patients Information

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Marital Status:
Currently:

Chief Complaint: *
Date Symptoms Began: *
Nature of Injury: *
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Personal injury
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Date of accident
Patients Address
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Street address, P.O. box, company name, c/o
Address Line 2:
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Check to receive information, news, and discounts by e-mail.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Insurance Information
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Insured Information
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Insured's Name:
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Insured's Address: if different from above
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Network Status:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
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Parent or Guardian's Information

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Marital Status:
Currently:

Chief Complaint: *
Date Symptoms Began: *
Nature of Injury: *
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Date of accident
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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