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

1. Full Payment is due at time of service
2. We may accept any assignable insurance with applicable coverage
3. We accept cash, checks, or Visa/Mastercard, Discover & American Express Card.

  • If you have insurance that covers acupuncture we will gladly submit your claims for you. You are responsible for your deductible, your co-pay and co-insurance amounts. If your insurance denies payment of a claim you are responsible for the billed charges. We will verify coverage prior to treatment. If for any reason we are not able to verify coverage prior to your treatment, you will be charged the pay at time of service fee for each treatment until verification is obtained. Any balance due on your treatments is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. We are not party to that contract. In the event we do not accept assignment of benefits we require that you pay the appropriate paying at time of service fee. In signing this document, you are assigning to this office benefits to which you are eligible to receive for care rendered in this office. Additionally in signing this document you authorize the release of any information to any insurance company, adjustor or attorney that will assist in the payment of a claim.
  • MasterCard, Visa, American Express, and Discover are accepted as well as cash and checks.
  • There will be a $15 fee for any returned checks.

I Agree
and understand that appointment time is reserved specifically for me. In the event of a missed appointment or an appointment cancelled with less than 24 hours notice, I may be charged a $50 fee. Insurance will not pay for a missed appointment.

  • We will do our best to accommodate you if you arrive late for your appointment. However, if you arrive more than fifteen minutes late and we are unable to accommodate you, we will consider it a missed appointment and enforce our financial policy.

Thank you for understanding our Financial Policy. Please let me know if you have any questions. By signing below you affirm that I have read the Financial Policy and understand and agree to this Financial Policy. A photocopy of this form shall be considered as effective as the original.

May 25, 2019

 

INFORMED CONSENT TO TREAT

As a patient I have the right to be informed about my health condition(s) and recommended treatment. This disclosure is to help me become better informed so that I may make the decision to give, or withhold, my consent as to whether or not to undergo care, having had the opportunity to discuss the potential benefits, risks and hazards involved.

I hereby request and consent to the performance of acupuncture treatments, naturophatic treatment and other procedures within the scope of the practice on me (or on the patient named below, for whom I am legally responsible) by Willard Sheppy, Dr Julia Mortlock and/or any allied health care provider who now or in the future treat me while employed by, working or associated with or serving as back-up for Willard Sheppy and/or Julia Mortlock, including those working at Valley Health Acupuncture or any other office or clinic, whether signatories to this form or not.

I understand that I have the right to ask questions and discuss to my satisfaction with Willard Sheppy or with the allied health care provider providing backup:

(1) my suspected diagnosis(es) or condition(s)

(2) the nature, purpose, goals and potential benefits of the proposed care

(3) the inherent risks, complications, potential hazards or side effects of treatment or procedure

(4) the probability or likelihood of success

(5) reasonable available alternatives to the proposed treatment procedure

(6) potential consequences if treatment or advice is not followed and/ or nothing is done.

 

The scope of practice of acupuncture is outlined below. I understand that Classical Chinese medicine and acupuncture evaluation and treatment may include, but are not limited to:

  • Acupuncture (insertion of specialized disposable stainless steel sterilized needles through the skin into underlying tissues at specific points on the bodys surface)
  • Use of electrical, mechanical and magnetic devices
  • Moxa (indirect burning of herbal material in the form of a loosely compacted herb or stick)
  • Cupping (used to relieve symptoms of pain and chest congestion in which glass cups are placed on the skin with a vacuum created by heat)
  • Tuina (ancient Chinese massage)
  • Dietary advice (based on traditional Chinese medicine theory)
  • Herbs (use of herbal formulas in the form of teas, powders, tinctures, pastes, and plasters, which may be taken internally or used externally as a wash. Formulas may include shells, minerals and animal materials)

Potential benefits: Restoration of the bodys maximal and optimal functioning capacity, relief of pain and other symptoms of disease, assistance with injury and disease recovery, and prevention of disease or its progression.

Potential risks:

  • Acupuncture: I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment.
  • Gua Sha/Cupping: Bruising is a common side effect of cupping and gua sha.
  • Herbs: I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may be an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant.
  • Electro-Acupuncture: Electro-acupuncture may be administered with the acupuncture. There may be certain adverse side effects such as: electrical shock, pain or discomfort, and the possible aggravation of symptoms existing prior to treatment
  • Acupressure-Massage: Acupressure-massage is used to modify or prevent pain perception and to normalize the body's physiological functions. There may be certain adverse side effects such as: muscle soreness or achiness and the possible aggravation of symptoms existing prior to the treatment.

Notice to pregnant women: All female patients must alert the provider if they have confirmed or suspect pregnancy as some of the therapies prescribed could present a risk to the pregnancy. Labor- stimulating techniques or any labor-inducing substances will not be used unless the treatment is specifically for the induction of labor and any treatment intended to induce labor requires a signed letter from a primary care provider authorizing or recommending such treatment.

Notice to individuals with bleeding disorders, pace makers, and/ or cancer: For your safety it is vital to alert your provider, Dr. Julia Mortlock, of these conditions.

Please review and check the following:

I Agree
and understand that  Willard Sheppy is not licensed to prescribe any controlled substances.

I Agree
and understand the US Food and Drug Administration has not approved nutritional, herbal and homeopathic substances; however these have been used widely in Europe, China and the USA for years.

I Agree
and understand that Willard Sheppy is not a psychologist or psychiatrist. Counseling services are provided for the support of improved lifestyle strategies.

I do not expect Willar Sheppy or any allied health care provider to be able to anticipate and explain all of the risks and complications, and I wish to rely on the provider to exercise all judgment during the course of the procedure based on the known facts. I also understand that it is my responsibility to request Willard Sheppy to explain therapies and procedures to my satisfaction. I further acknowledge that no guarantee of services have been made to me concerning the results intended from any treatment provided to me. By signing below I acknowledge that I have been provided ample opportunity to read this form or that it has been read to me. I understand all of the above and give my oral and written consent to the evaluation and treatment. I intend this as a consent form to cover the entire course of treatments for my present condition and any future conditions for which I seek treatment.

May 25, 2019

 

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.

May 25, 2019

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.

 

First Patients Name

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Chief Complaint: *

Date Symptoms Began: *
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Marital Status:
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Chief Complaint: *

Date Symptoms Began: *
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Seventh Patients Information

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Marital Status:
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Chief Complaint: *

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Eighth Patients Name

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Eighth Patients Date of Birth*
Eighth Patients Information

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Ninth Patients Name

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Ninth Patients Information

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Marital Status:
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Chief Complaint: *

Date Symptoms Began: *
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Tenth Patients Name

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Currently:

Chief Complaint: *

Date Symptoms Began: *
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Date of accident
Patients Address
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Insurance Information

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Insured Information
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Insured's Name:

Insured's date of birth

Insured's Address: if different from above

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Copay:

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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.
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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Other

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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