Licensed Acupuncturist, Herbalist, and Massage Therapist
Ancient Roots Acupuncture Protects Your Health Information and Privacy
Dear Valued Patient,
This notice describes our 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 our office, we 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
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.
Types of information that we gather and use:
In administering your health care, we gather and maintain information that may include non-public
• 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).
You may be able to access and correct personal information we have collected about you,
(information that can identify you - e.g. your name, address, Social Security number, etc.).
We value our relationship, and respect your right to privacy. If you have questions about our privacy
guidelines, please call us during regular business hours at (860)578-9865.