Notice Of HIPAA

First Name:
Last Name:

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights
You have the right to:

  • Get a copy of your paper or electronic medical record
  • Correct your paper or electronic medical record
  • Request confidential communication
  • Ask us to limit the information we share
  • Get a list of those with whom we’ve shared your information
  • Get a copy of this privacy notice
  • Choose someone to act for you
  • File a complaint if you believe your privacy rights have been violated

Your Choices
You have some choices in the way that we use and share information as we:

  • Tell family and friends about your condition
  • Provide disaster relief
  • Include you in a hospital directory
  • Provide mental health care
  • Market our services and sell your information
  • Raise funds

Our Uses and Disclosures
We may use and share your information as we:

  • Treat you
  • Run our organization
  • Bill for your services
  • Help with public health and safety issues
  • Do research
  • Comply with the law
  • Respond to organ and tissue donation requests
  • Work with a medical examiner or funeral director
  • Address workers’ compensation, law enforcement, and other government requests
  • Respond to lawsuits and legal actions

We have a detailed HIPAA NOTICE OF PRIVACY PRACTICES on our website and at Meridian Acupuncture & Wellness, which fully explains your rights and our obligations under the law. We may revise our NOTICE from time to time. The effective date at the top right-hand side of this page indicated the date of the most current NOTICE in effect. You can also view it on our website at

If you have any questions, concerns or complaints about the NOTICE or your medical information, please contact Meridian Acupuncture & Wellness (503) 692-9680. You may also send a written complaint to the US Department of Health and Human Services.

Patient's Name: