This Facility is required by law to provide you with this Notice so that you will understand how we may use or share
your information from your Designated Record Set. The Designated Record Set includes financial and health
information referred to in this Notice as “Protected Health Information” (“PHI”) or simply “health information.” We are
required to adhere to the terms outlined in this Notice. If you have any questions about this Notice, please contact Eric
Waltemate, D.C.
Each time you are admitted to our Facility, a record of your stay is made containing health and financial information.
Typically, this record contains information about your condition, the treatment we provide and payment for the
treatment. We may use and/or disclose this information to:
 plan your care and treatment
 communicate with other health professionals involved in your care
 document the care you receive
 educate health professionals
 provide information for medical research
 provide information to public health officials
 evaluate and improve the care we provide
 obtain payment for the care we provide
Understanding what is in your record and how your health information is used helps you to:
 ensure it is accurate
 better understand who may access your health information
 make more informed decisions when authorizing disclosure to others
The following categories describe the ways that we use and disclose health information. Not every use or disclosure in
a category will be listed. However, all of the ways we are permitted to use and disclose information will fall into one of
the categories.
 For Treatment. We may use or disclose health information about you to provide you with medical treatment. We
may disclose health information about you to doctors, nurses, therapists or other Facility personnel who are
involved in taking care of you at a Facility. For example, a doctor treating you for a broken leg may need to know if
you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the
dietitian if you have diabetes so that we can plan you meals. Different departments of a Facility also may share
health information about you in order to coordinate your care and provide you medication, lab work and x-rays.
We may also disclose health information about you to people outside the Facility who may be involved in your
medical care after you leave a Facility. This may include family members, or visiting nurses to provide care in your
 For Payment. We may use and disclose health information about you so that the treatment and services you
receive at a Facility may be billed to you, an insurance company or a third party. For example, in order to be paid,
we may need to share information with your health plan about services provided to you. We may also tell your
health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan
will cover the treatment.
For Health Care Operations. We may use and disclose health information about you for our day-to-day health
care operations. This is necessary to ensure that all residents receive quality care. For example, we may use
health information for quality assessment and improvement activities and for developing and evaluating clinical
protocols. We may also combine health information about many residents to help determine what additional
services should offer, what services should be discontinued, and whether certain new treatments are effective.
Health information about you may be used by our corporate office for business development and planning, cost
management analyses, insurance claims management, risk management activities, and in developing and testing
information systems and programs. We may also use and disclose information for professional review,
performance evaluation, and for training programs. Other aspects of health care operations that may require use
and disclosure of your health information include accreditation, certification, licensing and credentialing activities,
review and auditing, including compliance reviews, medical reviews, legal services and compliance programs.
Your health information may be used and disclosed for the business management and general activities of the
Facility including resolution of internal grievances, customer service and due diligence in connection with a sale or
transfer of the Facility. In limited circumstances, we may disclose your health information to another entity subject
to HIPAA for its own health care operations. We may remove information that identifies you so that the health
information may be used to study health care and health care delivery without learning the identities of residents.
We may disclose your age, birth date and general information about you in the Facility newsletter, on activities
calendars, and to entities in the community that wish to acknowledge your birthday or commemorate your
achievements on special occasions. If you are receiving therapy services, we may post your photograph and
general information about your progress.
 Business Associates. There are some services provided in our Facility through contracts with business
associates. Examples include medical directors, outside attorneys and a copy service we use when making copies
of your health record. When these services are contracted, we may disclose your health information so that they
can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect
your health information, however, we require the business associate to appropriately safeguard your information.
 Providers. Many services provided to you, as part of your care at our Facility, are offered by participants in one of
our organized healthcare arrangements. These participants include a variety of providers such as physicians (e.g.,
MD, DO, DC) labs, hospice caregivers, pharmacies, psychologists, LCSWs, and suppliers (e.g., prosthetic,
 Treatment Alternatives. We may use and disclose health information to tell you about possible treatment options
or alternatives that may be of interest to you.
 Health-Related Benefits and Services and Reminders. We may contact you to provide appointment reminders
or information about treatment alternatives or other health-related benefits and services that may be of interest to
 Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose health
information about you to a friend or family member who is involved in your care. We may also give information to
someone who helps pay for your care. In addition, we may disclose health information about you to an entity
assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
 As Required By Law. We will disclose health information about you when required to do so by federal, state or
local law.
 To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you to
prevent a serious threat to your health and safety or the health and safety of the public or another person. We
would do this only to help prevent the threat.
 Military and Veterans. If you are a member of the armed forces, we may disclose health information about you
as required by military authorities. We may also disclose health information about foreign military personnel to the
appropriate foreign military authority.
 Workers’ Compensation. We may disclose health information about you for workers’ compensation or similar
programs. These programs provide benefits for work-related injuries or illness.
 Reporting Federal and state laws may require or permit the Facility to disclose certain health information related
to the following:
Public Health Risks. We may disclose health information about you for public health purposes, including:

Prevention or control of disease, injury or disability
 Reporting births and deaths;
 Reporting child abuse or neglect;
 Reporting reactions to medications or problems with products;
 Notifying people of recalls of products;
 Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading
a disease;
 Notifying the appropriate government authority if we believe a resident has been the victim of abuse,
neglect or domestic violence. We will only make this disclosure if you agree or when required or
authorized by law.
o Health Oversight Activities. We may disclose health information to a health oversight agency for activities
authorized by law. These oversight activities may include audits, investigations, inspections, and licensure.
These activities are necessary for the government to monitor the health care system, government programs,
and compliance with civil rights laws.
o Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, we may disclose health
information about you in response to a court or administrative order. We may also disclose health information
about you in response to a subpoena, discovery request, or other lawful process by someone else involved in
the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the
information requested.
o Reporting Abuse, Neglect or Domestic Violence: Notifying the appropriate government agency if we believe a
resident has been the victim of abuse, neglect or domestic violence.
Law Enforcement. We may disclose health information when requested by a law enforcement official:
 In response to a court order, subpoena, warrant, summons or similar process;
 To identify or locate a suspect, fugitive, material witness, or missing person;
 About you, the victim of a crime if, under certain limited circumstances, we are unable to obtain your
 About a death we believe may be the result of criminal conduct;
 About criminal conduct at the Facility; and
 In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description
or location of the person who committed the crime.
 Coroners, Medical Examiners and Funeral Directors. We may disclose medical information to a coroner or
medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We
may also disclose medical information to funeral directors as necessary to carry out their duties.
 National Security and Intelligence Activities. We may disclose health information about you to authorized
federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
 Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution
or its agents health information necessary for your health and the health and safety of others.
Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made
only with your written permission. If you provide us permission to use or disclose health information about you, you
may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose
health information about you for the reasons covered by your written authorization. You understand that we are
unable to take back any disclosures we have already made with your permission, and that we are required to retain
our records of the care that we provided to you.
Although your health record is the property of the Facility, the information belongs to you. You have the following
rights regarding your health information:

Right to Inspect and Copy. With some exceptions, you have the right to review and copy your health information.You must submit your request in writing to Eric Waltemate, D.C. We may charge a fee for the costs of copying,
mailing or other supplies associated with your request.

Right to Amend. If you feel that health information in your record is incorrect or incomplete, you may ask us to
amend the information. You have this right for as long as the information is kept by or for the Facility .
You must submit your request in writing to Eric Waltemate, D.C. In addition, you must provide a reason for your
We may deny your request for an amendment if it is not in writing or does not include a reason to support the
request. In addition, we may deny your request if you ask us to amend information that:

 Was not created by us, unless the person or entity that created the information is no longer available to
make the amendment;
 Is not part of the health information kept by or for the Facility; or
 Is accurate and complete.
Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures”. This is a
list of certain disclosures we made of your health information, other than those made for purposes such as
treatment, payment, or health care operations.
You must submit your request in writing to Eric Waltemate, D.C. Your request must state a time period which may
not be longer than six years from the date the request is submitted and may not include dates before April 14,
2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The
first list you request within a twelve month period will be free. For additional lists, we may charge you for the costs
of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your
request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information
we use or disclose about you. For example, you may request that we limit the health information we disclose to
someone who is involved in your care or the payment for your care. You could ask that we not use or disclose
information about a surgery you had to a family member or friend.
We are not required to agree to your request. If we do agree, we will comply with your request unless the
information is needed to provide you emergency treatment.
You must submit your request in writing to Eric Waltemate, D.C. In your request, you must tell us (1) what
information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want
the limits to apply, for example, disclosures to your spouse.

Right to Request Alternate Communications. You have the right to request that we communicate with you
about medical matters in a confidential manner or at a specific location. For example, you may ask that we only
contact you via mail to a post office box.
You must submit your request in writing to Eric Waltemate, D.C. We will not ask you the reason for your request.
Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.
 Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice of Privacy Practices
even if you have agreed to receive the Notice electronically. You may ask us to give you a copy of this Notice at
any time.
 You may obtain a copy of .
To obtain a paper copy of this Notice, contact Eric Waltemate, D.C.
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 about you as well as any information we receive in the future. We will post a copy
of the current Notice in the Facility and on the website. The Notice will specify the effective date on the first page, in
the top right-hand corner. In addition, if material changes are made to this Notice, the Notice will contain an effective
date for the revisions and copies can be obtained by contacting the Facility administrator.COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with the Facility or with the Secretary of
the Department of Health and Human Services. To file a complaint with the Facility, contact Eric Waltemate, D.C. All
complaints must be submitted in writing. You will not be penalized for filing a complaint.

Eric Waltemate, DC, LAc (IN)
14 Park Place Suite A

loginThis acupuncture website is designed and maintained by myAcuWebsites.