NOTICE of PRIVACY POLICIES

Evergreen Acupuncture Clinic and Chinese Herbs is dedicated to providing service with respect for human dignity. Protecting your privacy and healthcare is fundamental in the course of our relationship. This notice will remain in effect until it is replaced or amended by changes in law.

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.

We gather personal information and health information in several ways:

•Information we receive from you•Information we receive from other healthcare providers

•Information we receive from third party payers

Protected Health is any information that includes:

•Demographic information•Information gathered by this practice as related to my past, present, and future.

•Information gathered by this office for past, present, future payments for providing

•healthcare services.

•Healthcare operations activities including quality assessment activities, credentialing, business management, and othergeneral operations, procedures and/or activities.

You may specifically authorize us to use protected health information for any purpose or to disclose our health information by submitting the authorization in writing. Such disclosures will be made to any personal representative you choose to make your protected health information available to.

Marketing: This office will not use your health information for marketing or communications without your writtenpermission.

Disclosure: This office may use or disclose your Protected Health Information when required by law.

Patient Rights

•Upon written request you have the right to access, review or receive copies of your healthcare records.•Upon written request you have the right to receive a list of items this office disclosed about your healthcare information

•You have the right to request that this office place additional restrictions on the disclosure of your Protected HealthInformation.

•You have the right to request that we amend your Protected Health Information; the request must be in writing.

•You have the right to receive all notices in writing

If you have any questions, complaints, or want more information, contact this office: US Dept. of Health and Human Services. (DHHS) Office of Civil Rights.200 Independence Ave. S. W. Room 509 F HHH Building, Washington, DC 20201