This is a comprehensive medical consent and privacy practices notice. This notice is for all persons who receive consult and/or treatment at OCOM’s clinics. This notice covers all of OCOM’s clinics, master's program intern, and resident and professional practices, as well as their clinical support staff. Please read this notice carefully. As a patient, you'll be asked to sign a similar form, acknowledging your understanding of what this notice says. A copy of this notice is posted in each of our clinics. This notice is available to any patient upon request.
General Information About Chinese Medicine
Acupuncture is a form of traditional medicine. It was developed in ancient China. It has been used successfully for many centuries. Acupuncture can treat many different health problems, and is known to be very safe. Treatments are done by highly trained practitioners, using fine solid metal needles. They are inserted at special locations just beneath the skin. The needles are sterile, and they are used one time only, and then safely discarded. Some patients do not feel the needles. Others feel some sensations (usually mild).
Electro-acupuncture is similar to acupuncture, but is of recent origin (20th century). A mild electric current is applied to the needles. Some patients feel a mild tingling sensation when electro-acupuncture is used.
Moxibustion is a traditional therapy that can be used with acupuncture or electro-acupuncture. Heat is applied near the skin at special locations. A traditional herb is often used in moxibustion treatments.
Cupping is another therapy that may be used by acupuncturists. It includes heat and suction. Special glass cups are often used. This therapy is frequently used on the back.
Traditional Chinese Herbs are used by acupuncturists to treat a variety of illnesses or painful conditions. Special herb formulas can be used along with acupuncture. Herbs can help the body’s systems to heal or work better. Herbs can be strong medicine, so it is important to follow the dosage directions carefully.
Tuina and Shiatsu are two forms of traditional massage. They are sometimes used alone; sometimes in addition to acupuncture. They may help with painful conditions. They may also help the body to feel better generally.
What to Expect at OCOM’s Clinics
If you have any questions about the following information, ask your practitioner.
Intern Teaching Clinic: I understand that this is a teaching clinic. Sometimes clinical students (interns) perform treatments with patients. All students are supervised by experienced licensed practitioners. These supervisors work as faculty members (teachers) at the college. Supervisors make sure that students perform the best possible treatments. I understand that sometimes students observe treatments. If this happens, supervisors may discuss the treatment with the observers. This helps students learn new skills.
Service Animals: I understand that sometimes service animals (e.g., guide dogs) may be allowed in the clinic. These animals may be helping other patients, or students. The front desk can provide more information.
Primary Care Doctor: A primary care doctor is often a patient’s first contact for medical help. I understand that in Oregon, acupuncturists are not considered primary care doctors. I understand that I should have my own primary care doctor before seeking treatment. If I do not have a doctor, I will inform my practitioner about this. I understand that I may be asked to see a doctor before being treated.
Financial Policies: I acknowledge and understand that I am responsible for any and all fees that I incur at time of service which are not covered by my insurance plan. Late cancellations (less than 24 hours notice) and missed appointments are billed to patient accounts. A finance charge of 1.5% per month (18% APR) is added to any overdue accounts (those not paid within 30 days).
Information about Potential Risks or Side Effects: I understand that treatments I receive may have certain risks or side effects. My practitioner will discuss these issues with me. Sometimes my condition may get worse for a while, but this is usually temporary. Sometimes acupuncture can cause pain or discomfort. Minor bruising or bleeding may occur. Sometimes patients may feel dizzy or faint. In extremely rare cases, spontaneous miscarriage and/or lung puncture (pneumothorax) may result. Acupressure or massage may sometimes cause muscles to feel sore or achy.
Electro-acupuncture can sometime cause tingling or very mild electric shocks. Moxibustion may (very rarely) cause burns or scarring. Cupping may cause bruising or (very rarely) burning or scarring. Chinese herbs may sometimes cause stomach pain, digestive discomfort, or changes in bowel movements. If used on the skin, herbs may cause skin irritation. If I take herbs and they cause me problems, I understand that I should stop taking them immediately. I will call the clinic if this occurs.
Notice of Privacy Practices
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.
About This Notice
This Notice will tell you about the ways we may use and disclose health information that identifies you. We also describe your rights and certain obligations we have regarding the use and disclosure of Health Information. We are required by law to maintain the privacy of Health Information that identifies you; give you this Notice of our legal duties and privacy practices with respect to your Health Information; and follow the terms of our Notice that are currently in effect.
The following categories describe different ways that we may use and disclose Health Information:
For purposes of treatment: I understand that OCOM will use my health care information to treat me, including diagnosis and treatment. Treatment may include acupuncture, massage and herbs. I understand that for the purposes of diagnosis and treatment my protected health information may be disclosed but not sold to another health care provider. I understand that OCOM does its best to protect my medical information, but that in acupuncture group treatment and massage clinic care is administered in an open-room setting, thus other people may hear or see my treatment.
For payment services: I understand that my health care information may be used to receive payment for services and products. The information on or accompanying the bill may include my identification, as well as the herbs I am taking.
For health care operations: I understand that my protected health information may be disclosed for all activities that are included within the definition of “health care operations” as defined in the federal Privacy Regulations. For example, OCOM may use information in my health record to monitor the quality of supervision and student performance and to train acupuncture personnel.
Patient Care Research: I understand that OCOM performs patient care research at this clinic. All studies use strict ethical guidelines and undergo an ethical review process. These studies can be important for improving care in the future. Beginning today, I agree to allow my information to be used for studies of this kind. I understand that my privacy will always be protected. I understand that I may ask OCOM to stop using my information for research purposes at any time in the future. If I choose to stop participating, I will let the Clinic Director know in writing.
For fund development: I understand that OCOM is allowed by HIPAA regulations to use certain information (name, address, telephone numbers, dates of service, age, gender) to contact patients regarding efforts to raise funds to expand and improve the services and programs provided to the community. I understand that my willingness to engage in fund raising events will have no effect on my clinical care and I may opt out at any time. Requests must be made in writing and submitted to the OCOM HIPAA Compliance and Privacy Office.
Friends and family: OCOM may disclose protected health information to friends and family in case of an emergency to the extent necessary to help with health care or with payment of health care. Using their judgment as health care professionals, the acupuncture staff may disclose protected information with a family member, other relative, close personal friend, or any person identified as being involved in your health care.
Reminder calls: OCOM may contact you to provide reminders of herbal refills or appointments or other health related services that may be of interest to you.
Other covered entities: OCOM may disclose your protected health information to another covered entity to conduct health care operations in the area of quality assurance activities, or accreditation, certification, licensing or credentialing.
Disclosure to the U.S. Department of Health and Human Services: When the U.S. Department of Health and Human Services is investigating or determining our compliance with the federal Privacy Regulations, OCOM is required to disclose your protected health information to the DHHS.
Abuse or neglect: As an institution of higher learning, mandatory reporting rules require that we disclose protected health care information to appropriate authorities if we believe that an elderly individual or child may be a possible victim of abuse, domestic violence, neglect, or other crimes.
Serious threat to health or safety: We may disclose your protected health information if we believe that the disclosure is necessary to prevent a serious threat to your health or safety or the health and safety of the public or another person.
Public health and safety: OCOM may release your protected health information to public health or legal authorities charged with preventing or controlling disease, injury or disability. For example, we may use information in your health record to the Food and Drug Administration relative to adverse events regarding drugs, foods, supplements, and other health products or to post marketing surveillance to enable product recalls, or replacements.
Business Associates: We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
Worker’s compensation: We may release your protected health information if you are involved in a workman’s compensation case.
Law enforcement: OCOM may disclose your protected health information to law enforcement agencies in response to a court order, subpoena, discovery request, administrative order, or other lawful process by another person involved in a dispute involving a patient, but only if efforts have been made to tell the patient about the request or to obtain an order protecting the requested health information.
Other required or permitted disclosures: OCOM may disclose your health care information under the following circumstances:
- Whenever required to do so by law;
- To a correctional institution or its agents, if a patient is or becomes an inmate of such an institution, when necessary for the patient’s health or the health and safety of others;
- To notify, or assist in notifying a family member, personal representative, or another person responsible for the patient’s care or the patient’s location, or general condition;
- To the military authorities under certain circumstances when the patient is a member of the Armed Forces;
- To authorized federal officials for intelligence, counterintelligence, and other national security activities; for compliance audits by regulatory bodies or payers.
Authorized Use and Disclosure
I understand that OCOM will obtain my written Authorization before using or disclosing my protected health care information for purposes other than those listed above or otherwise permitted or required by law. I may revoke an Authorization in writing at any time. Upon receipt of this revocation OCOM will stop using or disclosing my protected health care information except to the extent that OCOM may have already taken action in reliance on previous authorization.
Guidelines around providing protected health information to an OCOM practitioner via e-mail
Information you submit through use of your own e-mail program is not secure. As effective as modern security practices are, no physical or electronic security system is impenetrable. We cannot guarantee the security of our electronic information systems, nor can we guarantee that information you supply won't be intercepted while being transmitted over the Internet. If you choose to send confidential or protected information over the internet, you do so solely at your own risk. Patients who choose to use the Internet to send protected information must must have signed documentation in their file stating they recognize their information is at risk of protected health information (PHI) breach.
Right to request restrictions: I understand that I have the right to request that OCOM restrict how my protected health information is used or disclosed in carrying out treatment, payment, or health care operations. Requests must be made in writing to the OCOM HIPAA Compliance and Privacy Office (see below). The request must tell OCOM: 1) the information to be limited and disclosed and 2) how I want OCOM to limit and/or disclose the information. I understand that OCOM is not required to agree to the requested restrictions, but if it does, OCOM will abide by the agreement except in an emergency.
Right to access protected health information: I understand that have the right to look at or obtain a confidential copy of my protected health information or billing/payment information. Requests must be made in writing to the OCOM HIPAA Compliance and Privacy Office (see below). OCOM may charge me a reasonable fee for copies and postage (if mailed). OCOM may deny my request to inspect and copy my protected health information in certain limited circumstances. If denied access to my protected health information, I may request that the denial be reviewed.
Right to access to electronic medical records: At this time, patient medical records have not been stored electronically and therefore electronic medical records cannot be provided to OCOM patients.
Accounting of Disclosures: I understand that I have the right to receive an accounting of the disclosures of my protected health information (PHI) OCOM has made on or after April 14, 2003. OCOM will provide the date of the disclosures, the name of the person or entity to which my PHI was disclosed, a description of the PHI disclosed, and the reason for the disclosure. Effective in September 2013, I have the right to restrict disclosures to an insurance company when I have paid for treatment out-of-pocket. Restriction requests must be made in writing and submitted to the OCOM HIPAA Compliance and Privacy Office.
Amendments to Health Care Information: I understand that I have the right to request that OCOM amend my protected health information if I feel that it is incomplete or incorrect. Requests must be made in writing to the OCOM Privacy Office (see below) and explain why the information should be amended. If OCOM did not create the information I want amended or in certain other circumstances, OCOM may deny the request. If the request is denied, a written explanation will be provided. I have the right to file a statement of disagreement with the decision.
How to Learn About Special Protections for HIV, Alcohol and Substance Abuse, Mental Health and Genetic Information: Special privacy protections apply to HIV-related information, alcohol and substance abuse information, mental health information, and genetic information. Some parts of this general Notice of Privacy Practices may not apply to these types
of information. If your treatment involves this information, you may contact the Privacy Officer for more information about these protections.
Privacy Breach Notification: You have the right to be notified if a breach occurs that may have compromised the privacy or security of your Health Information.
For More Information or to Report a Problem
I understand that if I would like additional information or have questions the privacy practices, I may contact the OCOM HIPAA Compliance and Privacy Office (see below). If I believe my privacy rights have been violated, I may file a complaint with OCOM or with the Department of Health and Human Services. I understand that OCOM supports my right to protect the privacy of my protected health and financial information and will not retaliate in any way if I choose to file a complaint with OCOM or with the Department of Health and Human Services.
Changes To This Notice
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for Health Information we already have, as well as any information we receive in the future. We will post a copy of the current Notice at each OCOM clinic office or outpatient location and on our website.
OCOM HIPAA Compliance and Privacy Officer
OCOM Clinic, 75 NW Couch, Portland, OR 97209