Acupuncture and Chinese Herbal Medicine

Providing Acupuncture in Bellevue and Monroe Washington

Acupuncture and Chinese Herbal Medicine in Bellevue, Kirkland and Redmond Washington

Privacy Policy

Notice of Privacy Practices

We respect your privacy and 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. The privacy of your health information is important to us.

Health and Insurance Portability and Accountability Act of 1996 (HIPPA)

HIPPA is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us, in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

Our Pledge Regarding Your Medical 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 required to maintain the privacy of your health information and how we may use and disclose your health information. We do not use your health information in our office or disclose it outside of our office without your written permission. In some limited situations, the law requires us to disclose your health information without either a written or verbal consent.

Use and Disclosure 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 healthcare operations in this office. We are allowed to refuse to treat you if you do not sign the consent form. We are permitted to use and disclose your healthcare records for the purpose of treatment, payment and healthcare operations.

  1. Treatment means providing coordination, or managing healthcare related services by one or more healthcare providers. For example, we may need to share information with other providers or specialists involved in your care.

  2. Payment means activities such as obtaining reimbursement for services, verifying coverage, billing or collection activities and utilization review. For example, we disclose treatment information when billing a medical plan for your acupuncture services and treatments.

  3. Healthcare operations include the business aspects of running our practice. For example, patient information may be used for training purposes or quality assessment.

Unless you request otherwise, we may use or disclose health information to a family member or other personal representative to the extent necessary to help with your healthcare or with payment for your healthcare. In addition, we may use your confidential information to remind you of your appointments by leaving messages at home and/or work. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

Use and Disclosure Without Consent

In some limited situations, the law requires us to use and disclose your health information without your consent. Some of these examples are:

  • Disclosures in response to subpoenas or orders of the court.

  • Disclosures for law enforcement purposes, such as to provide information about someone who is a suspected victim of a crime, or to provide information about a crime at our office.

  • Disclosure related to worker’s compensation programs.

  • When state or federal law mandates that 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 of suspected abuse, neglect or domestic violence.

Your Rights Regarding Your Health Information

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

  • 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 a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

  • The right to ask us to communicate to you in a confidential way, such as by phoning you at work rather than at home or by mailing health information to a different address. Please provide a written request.

  • The right to ask to see or to get photocopies of your health information. You may be charged a fee for a copy of your records. We do charge a fee to release your records to an outside source other than a healthcare provider. (i.e. lawyers, research firms, etc) Please complete our written records request for billing or medical record release.

  • The right to receive an accounting of disclosures of protected health information.

  • The right to amend your protected health information.

  • The right to obtain a paper copy of this notice from us upon request.

This notice is effective as of September 21, 2004, and we are required to abide by the terms of Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post any revised Notices of Privacy Practices. You may also request a copy of any revisements.

You have the right to file a formal, written complaint with us at the address below, or with the Department of Health and Human Services, Office of Civil Rights, in the event you feel that your privacy rights have been violated.

For more information please contact: For More Information or to file a complaint:


Attn: Privacy Officer

Source Healing and Wellness Center

12737 Bel-Red Road, Ste 210

Bellevue, WA 98005

(425) 533-7320


US Dept of Health & Human Services

Office of Civil Rights

200 Independence Ave SW

Washington DC 20201

(877) 696-6775


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© 2009 Kaira Jorgensen, L.Ac.

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Source Healing and Wellness Center
12737 Bel-Red Road, Ste 210
Bellevue, WA 98005
(425) 533-7320