DRAFT — pending approval and effective date

Effective date: To be entered on publication. Status: Draft for practice/legal review; do not label final until operational practices are confirmed.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Privacy Officer: Dr. Jennifer Huang Tsai, DC, L.Ac.
Practice: Blissful Wellness Acupuncture & Chiropractic
Address: 8002 Haven Avenue, Rancho Cucamonga, CA 91730
Telephone: (909) 276-7168
Email: info@blissful-wellness.com
For sensitive records or identity verification, please contact our office to arrange an appropriate secure communication method; ordinary email may not be suitable.

Your rights

Access your records. You may request to inspect or obtain an electronic or paper copy of medical records and other health information we maintain about you. We generally respond within 30 days under HIPAA, subject to permitted extensions, applicable California requirements and lawful fees.

Request corrections. You may ask us to amend information that is inaccurate or incomplete. If we decline, we will explain our decision and your rights in writing, generally within 60 days under HIPAA.

Ask for confidential communications. You may ask us to contact you using a particular telephone number, mailing address or other reasonable method. We will accommodate reasonable requests.

Request restrictions. You may ask us not to use or disclose certain information for treatment, payment or health care operations. We do not have to agree to every request. If you pay in full out of pocket for care, you may require us not to disclose information about that care to your health plan for payment or operations, unless disclosure is otherwise required by law.

Request an accounting. You may request an accounting of certain disclosures made during the previous six years, subject to exceptions and applicable rules.

Receive a copy of this notice. You can request a paper or electronic copy at any time.

Choose a representative. A legally authorized personal representative may exercise applicable rights on your behalf after we confirm their authority.

Make a complaint without retaliation. Contact our Privacy Officer or file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at https://www.hhs.gov/hipaa/filing-a-complaint/. We will not retaliate against you for making a complaint.

Your choices

In certain circumstances, you may tell us your preferences regarding disclosures to family members, friends or others involved in your care or payment for care, and disclosures for disaster relief. Where the law requires written authorization—such as most uses or disclosures for marketing, sale of health information, and most disclosures of psychotherapy notes—we will obtain it. You may revoke an authorization in writing, subject to actions already taken in reliance on it.

How we may use and disclose information

Treatment: To diagnose, coordinate, provide or refer for care, including sharing information with treating professionals where permitted.

Payment: To verify benefits, submit claims, collect payment and address insurance or billing matters.

Health care operations: To operate the practice, perform quality assessments, manage records, arrange services and communicate about care.

When required or permitted by law: We may make disclosures that satisfy applicable legal conditions for public health, reporting abuse or neglect, health oversight, responding to legal process, certain law-enforcement purposes, medical examiners or funeral directors, workers’ compensation, and preventing serious threats to health or safety. Additional limits can apply under federal and California law.

Research and other special purposes: Any use or disclosure will be subject to applicable privacy rules, authorizations, waivers and safeguards.

Business associates: We may use service providers that handle protected health information on our behalf only under arrangements and safeguards required by applicable law, including business associate agreements where necessary. Specific vendor configurations and agreements must be verified before this statement is finalized.

More protective information: Certain types of records may have special confidentiality protections under California or federal law, including some mental-health, reproductive-health and substance-use-disorder records. We follow applicable more protective requirements.

42 CFR Part 2 records: To the extent we receive or maintain records protected by 42 CFR Part 2, additional rules apply. Such records generally cannot be used or disclosed in civil, criminal, administrative or legislative investigations or proceedings against a patient without the patient’s specific consent or an appropriate court order and subpoena as required by Part 2. Other Part 2-specific limits and patient choices apply. [Practice reviewer: confirm if the clinic receives or maintains Part 2 records and whether any additional required notice language applies.]

Our responsibilities

We must protect the privacy and security of protected health information; notify affected individuals of a breach when required by law; follow the notice currently in effect; and provide a copy of this notice on request. We will not use or disclose information in a manner not described here unless permitted by law or authorized by you. We may update this notice and apply the updated notice to information we maintain, and will make the revised notice available at the clinic and on our website.

Questions and complaints

Contact Dr. Jennifer Huang Tsai, Privacy Officer, at (909) 276-7168 or info@blissful-wellness.com, or write to 8002 Haven Avenue, Rancho Cucamonga, CA 91730. Please do not send detailed medical information through unencrypted general email.