Joyful Balance Wellness, LLC
Notice of Privacy Practices (HIPPA)
Please review the information below carefully.
This notice describes our office’s policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected.
The Health Insurance Portability and Accountability Act of 1996 (HIPPA):
HIPPA is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form are kept confidential. This act provides the patient rights to understand and control how your health information is used. HIPPA provides penalties for covered entities that misuse personal health information.
We respect our legal obligation to keep health information that identifies you private. As obligated by law, we have prepared this explanation of how we are require to maintain the privacy of your health information and how we may use it and disclose your health care information. We do not use your health information inside our office our outside without your written permission. In some limited cases, the law requires us to disclose your health care information without either a written or verbal consent.
Safeguards in place at our office include:
Limited access to facilities where information is stored.
Policies and procedures for handling information.
Requirements for third parties to contractually comply with privacy laws.
All medical files and records (including email, regular mail, telephone, and faxes sent) are kept on permanent file.
Use and Disclose With Consent:
We will ask you to sign a consent form allowing us to use and disclose your health information for purposes of treatment, payment, and health care operations in this office. Treatment can be stopped with refusal to sign the form. We are permitted to use and disclose health information to a family member or other personal representative to the extent necessary for treatment or payment related to your healthcare. In addition, we may use your confidential information to remind you of appointments by leaving you messages at home or work. Any other uses and disclosures will be made only with your written authorization.
Use and Disclosure Without Consent:
In some limited situations, the law requires us to use and disclose your health information without your permission. These examples include:
When state or federal law mandates certain health information be reported for a specific purpose.
For public health purposes, such as contagious disease reporting and notices to and from the FDA regarding drugs and medical devices.
Disclosure to government authorities about victims or suspected abuse, neglect, or domestic violence.
Uses and disclosures for health oversight activities, such as for the audits by Medicare, or for investigation of possible violations of health care laws.
Disclosures in response to subpoenas of orders of the court.
Disclosures for law enforcement purposes, such as to provide information about someone who is suspected to be a victim of a crime, or to provide information about a crime in our office.
Disclosure related to worker’s compensation programs.
Your Rights Regarding Your Health Information:
You have the following rights with respect to your protected health information, which you can exercise in writing to our office:
The right to request restrictions on certain uses and disclosures of protected health information, including those related to the disclosure of family members, other relatives, close personal friends, or any other person identified by you. We are however, not required to agree to the request restriction. If we do agree the restriction, we must abide by it unless you agree in writing to remove it.
The right to ask to communicate with you in a confidential way, such as contacting you at work rather than at home. Please provide a written request. The right to see or get photocopies of your health information. You may have to pay for photocopies in advance. We do charge a fee to release your records to an outside source other than a health care provider. Please complete our written records request for billing or medical records release.
The right to receive an accounting disclosure of protected health information.
The right to amend your protected health information.
The right to obtain a paper copy of this notice at your request.
You have the right to file a formal, written complaint with the Secretary of the US Department of Public Health and Human Services in the event you feel your privacy rights have been violated.
I hereby voluntarily request and consent to be treated, or give permission for my child/ward to be treated, with acupuncture; electro-acupuncture; acupressure and other techniques based on Traditional Asian Medicine. I understand I may be given recommendations on diet, lifestyle and nutritional or herbal supplements and it is my decision whether or not to follow these recommendations. I understand I may be treated with the insertion of needles or other non-insertion techniques; electrical stimulation; or touch/palpation. I have not been guaranteed any success concerning the uses and effects of these treatments. I understand that I am free to discontinue treatment at any time.
Possible Side Effects/Healing Reactions
I understand that these treatments may result in certain side effects, including local bruising; slight bleeding; burns; pneumothorax; spontaneous miscarriage; fainting; temporary pain or discomfort; and temporary aggravation of symptoms existing prior to treatment.
I understand that I should consult a licensed physician for appropriate medical evaluation and treatment of the conditions for which I am seeking acupuncture treatment. Treatment from this practitioner does not substitute for appropriate medical treatment by a licensed physician. If there is a worsening of my ailment or condition, or if it does not improve within the time estimated by the acupuncturist at the beginning of treatment, or if a new ailment or condition arises, I should again consult a licensed physician. If I am presently under the medical care of a physician, I am advised to continue all medications and treatments as prescribed until such time as my physician deems it appropriate to reduce or discontinue the medications or treatments. I certify that I will inform Joyful Balance Wellness of all known physical, mental, and medical conditions and medications, including possible pregnancy, and that I will notify Joyful Balance Wellness of any changes.
Infectious Disease/Clean Needle Procedures
I understand that there is infectious disease carried through the air, through physical contact, and through body fluids. I understand that universally prescribed precautions will be utilized during treatments to guard against the spread of infection, including the use of sterilized, prepackaged disposable needles. Needles that are used for my treatment are used only on me, and are inserted according to clean procedures based on nationally prescribed standards. Needles are disposed of as medical waste immediately after use. I understand that my questions about the safety of any procedure or treatment or the precautions taken by the practitioner are most welcome and will be answered as fully as possible. I understand I have the right to refuse any treatment or procedure.
Payment and Cancellation Policies
Current fees are: Initial Acupuncture Treatment: $145 / Follow-up Treatment $75 / AcuDetox Treatment: $45
Full payment is expected at the time services are rendered. Sliding Fees may be available upon request.
A $35 fee is charged for the first check returned by the bank. If a second check is returned, subsequent payments must be cash.
If you must cancel your appointment, we require a 24 hour notice to avoid a $60 cancellation fee.
I understand that the Novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organizaiton (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand that COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.
I understand that I am the decision maker for my healthcare. Part of this office's role is to provide me with information to assist me in making informed choices. This process is often referred to as "informed consent" and involves my understnaing and agreementregarding recommended care, and the blenefits and risks associated with the provision of health care during a pandemic. Given the current limiations of COVID-19 virus testing, I understand determing who is infected with COVID-19 is exceptionally difficult.
I knowingly and willingly consent to the treatment with the full understanding and disclosure of the risks associated with receiving care during the COVID-19 Pandemic. I confirm all of my questions were answered to my satisfaction.
I have read, have had read to me, the above COVID-19 risk informed consent to treat. I appreciate that it is not possible to consider every possible complication to care. I have also had an opprountiy to ask questions about its content and by signing below, I agree with the current or future recommendation to receive care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future conditions for which I seek care from this office.
This waiver will remain effective until laws and mandates relevant to COVID-19 are lifted.