HEALTH INFORMATION PRIVACY 

Our Clinic Protects Your Health Information and Privacy

Dear Valued Patient,

This notice describes the 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.

In order to maintain the level of service that you expect from the office, I may need to share limited personal medical and financial information with your insurance company¸ with Worker’s Compensation (and your employer as well in this instance), or with other medical practitioners that you authorize.

Safeguards in place at our office include:

• Limited access to facilities where information is stored.

• Password protected Electronic Medical Record storage.

• Requirements for third parties to contractually comply with privacy laws.

• All medical files and records, including email are kept on permanent file.

Types of information that we gather and use:

In administering your health care, I gather and maintain information that may include non-public personal information:

• About your financial transactions with us (billing transactions).

• From your medical history, treatment notes, all test results, and any letters, faxes, emails or telephone conversations to or from other health care practitioners.

• From health care providers, insurance companies, workman’s comp and your employer, and other third part administrators (e.g. requests for medical records, claim payment information).

In certain states, you may be able to access and correct personal information I have collected about you, (information that can identify you - e.g. your name, address, Social Security number, etc.).

I value our relationship, and respect your right to privacy. If you have questions about the privacy guidelines, please contact Daphne Lim.

I understand that as part of my healthcare, or my legal dependent’s healthcare, this organization originates and maintains health records describing health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care of treatment.

I understand that this information serves as:
• A basis for planning care and treatment.
• A means of communication among the many healthcare professionals who contribute to care.
• A source of information for applying diagnostic and medical information to a bill.
• A means by which a third-party payer can verify that services billed were actually provided.
• A tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare professionals.

I understand that I have the right:
• To object to the use of health information for directory purposes.
• To request restrictions as to how this health information may be used or disclosed to carry out treatment, payment or healthcare operations – and that the organization is not required to agree to the restrictions requested.
• To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereupon.

Thank you,

Daphne Lim Holistic Medicine LLC