Healing Medicine
Robin Bonazzoli M.Ac. Lic.Ac. Dipl.Ac. MQP
Bolton Corners Bldg., 563 Main Street, Bolton, MA 01740

HIPAA / Health and Consent Forms

You may wish to fill out the following consent, policy and health history documents and bring them to your first appointment. If so, please read the document below: “Notice of Privacy Practices and Patient’s Rights“.

Please note that there are fourteen pages, eleven of which are detailed questions concerning your health history so that you can best be served. If you cannot fill out the forms before your appointment time, please plan to arrive at least 30 minutes early to do so in the waiting room before your session. The appointment duration that we have scheduled for you does not include time for filling out forms.

Notice of Privacy Practices and Patient’s Rights

What is HIPAA?

The Federal law that protects the confidentiality of your health information is called the Health Insurance Portability and Accountability Act (HIPAA).  According to law, your “protected health information” is any information about you that can identify you. This includes your health records, name, telephone number, and address; and dates such as your birth date, start of treatment and appointments.  And so, in compliance with HIPAA, Country Well Acupuncture clinic protects how your health information can be used in the clinic as well as via correspondence to you by phone, fax, mail and email. In essence, your health information will not be shared with anyone without your written consent unless required by state of federal law.

How Your Health Information May Be Used

This clinic will use and communicate your health information only for the purposes of: providing the best possible care during treatment, obtaining payment, conducting the clinic, and complying with Massachusetts and Federal regulations. Your health information will not be used for other purposes unless you the patient (or your legal guardian) have been asked for and have voluntarily given written permission.

To Obtain Insurance Reimbursement

Your health information may be included with an invoice to help you collect payment for treatment from your health provider, if you have requested such an invoice in writing.

To Conduct Clinic Operations

Your health information may be disclosed during audits by government appointed agencies as part of their quality assurance, compliance reviews and licensing procedures.

Patient Reminders

Because the clinic believes regular care is very important to your health, you may be reminded of a scheduled appointment, or that it is time for you to contact us to make an appointment. Additionally, the clinic may contact you to follow-up on your care and inform you of treatment options or services that may be of interest to you or your family.  These communications may include:  postcards, letters, telephone correspondences and messages, or electronic reminders such as emails (unless you state that you do not want to receive these reminders.)

Abuse, Violence or Neglect

This clinic will notify government authorities if the patient or the patient’s family is a victim of abuse, neglect or domestic violence.  This disclosure will only be made: if the clinic is compelled by ethical judgment, when required or authorized by law, or with the patient’s agreement.

Public Health and National Security

This clinic may be required to disclose to government officials a patient’s health information if  necessary to complete an investigation related to public health and safety or national security.