Notice Of HIPAA NOTICE OF PATIENT PRIVACY PRACTICESHEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (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 RightsYou have the right to:Get a copy of your paper or electronic medical recordCorrect your paper or electronic medical recordRequest confidential communicationAsk us to limit the information we shareGet a list of those with whom we’ve shared your informationGet a copy of this privacy noticeChoose someone to act for youFile a complaint if you believe your privacy rights have been violatedYour Choices You have some choices in the way that we use and share information as we:Tell family and friends about your conditionProvide disaster reliefInclude you in a hospital directoryProvide mental health careMarket our services and sell your informationRaise fundsOur Uses and Disclosures We may use and share your information as we:Treat youRun our organizationBill for your servicesHelp with public health and safety issuesDo researchComply with the lawRespond to organ and tissue donation requestsWork with a medical examiner or funeral directorAddress workers’ compensation, law enforcement, and other government requestsRespond to lawsuits and legal actionsWe 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 www.meridianacupuncture.com.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: Date: Your submission is being processed. You can print out your form by following this unique link. Do not share it with anyone. https://meridianacupuncture.com/resources/forms/patient-form/print-form/?auth={{code}} Thanks for your submission. Please print this form out or save as PDF and bring it with you to your appointment in case the submission failed.Secure HIPAA compliant forms by FireSpike LLC 1-800-996-9689