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Health Insurance Portability & Accountability Act


Typically, this record contains your treatment plan, your history and physical, any other information that you provide to us, and billing records. This record serves as a:
1. The basis for planning your treatment;
2. Means of communication for or between our acupuncturists and staff, and any health care providers, if any, that you wish us to share such information with;
3. A tool for assessing and continually working to improve the care rendered at AcuHaus.


When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

  • Get an electronic or paper copy of your medical record

    • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

    • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

  • Ask us to correct your medical record

    • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

    • We may say “no” to your request, but we’ll tell you why in writing within 60 days.

  • Request confidential communications

    • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

    • We will say “yes” to all reasonable requests.

  • Ask us to limit what we use or share

    • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

    • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

  • Get a list of those with whom we’ve shared information

    • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

    • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

  • Get a copy of this privacy notice

    • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

  • Choose someone to act for you

    • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

    • We will make sure the person has this authority and can act for you before we take any action.


For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care

  • Share information in a disaster relief situation.

  • If you are not physically able to tell us your preference we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

Only if you give us written permission: Marketing purposes.


In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.

How do we typically use or share your health information? We typically use or share your health information in the following ways.

  • We can use your health information and share it with other professionals who are treating you.

  • We can use and share your health information to run our practice, improve your care, and contact you when necessary.

  • We can use and share your health information to bill and get payment from you or another party.

  • We may require you to provide us certain information to verify your identification. We may use different methods to confirm your identification, including but not limited to, photographs, fingerprints or other biometrics.


This information will be stored in our system for identification purposes only and will not be utilized for any other purposes.

  • We may use and disclose medical information to remind you of an appointment, if applicable.

  • We will share medical information about you when required to do so by federal or state laws or regulations.

  • Address workers’ compensation, law enforcement, and other government requests


We can use or share health information about you:

  • For workers’ compensation claims.

  • For law enforcement purposes or with a law enforcement official.

  • With health oversight agencies for activities authorized by law.

  • We can use or share your information for health research.

  • Respond to lawsuits and legal actions: We can share health information about you in response to a court or administrative order, or in response to a subpoena.


Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information:



By voluntarily signing this form, as the client or as the parent/guardian, I confirm that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions, agree to the cancellation policy, and understand my privacy rights as outlined above.


I agree with the current or future recommendations for care for either myself or my child. I intend this consent form to cover the entire course of treatment for my or my child's present condition and for any future condition(s) for which I or my child seeks treatment.

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