North Coast Natural Health and Acupuncture ClinicDr. Tamara Macdonald ND, LAc

ACUPUNCTURE INTAKE FORM

Name

Preferred Name

Date of Birth

Age

Gender

Highest Education Level

Job Title

Nature of Business

Primary Address

Home Phone

Work Phone

Cell Phone

Email

Emergency Contact

Physician

Referred by: Provider Website Friend or Family Member Other

First Middle Last

Name Phone Number

Number, Street Apt. #

Number, Street Apt. #

Name Phone Number

Fax

City State Zip

City State Zip

Male Female

High School Undergraduate Post-Graduate

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3929 Center Road • Brunswick, OH 44212 • 330.460.5155

How do these conditions impair your daily activities: ________________________________________________

Other treatments you have used: _________________________________________________________________

How long have you had these symptoms? _________________________________________________________

What makes these symptoms better? _____________________________________________________________

What makes these symptoms worse? _____________________________________________________________

Have you received a medical diagnosis? Yes No If yes, what is it? _______________________________

PATIENT MEDICAL HISTORY

How was your childhood health? ________________________________________________________________

Hospital visits/stays: __________________________________________________________________________

Immunizations: ______________________________________________________________________________

Surgeries: ___________________________________________________________________________________

Accidents/Injuries? ___________________________________________________________________________

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Describe Problem Prior Treatment/Approach Example: Post Nasal Drip X Antibiotics X

Mild

Mod

erat

e

Seve

re

Exce

llent

Goo

d

Fair

Please list current and ongoing problems in order of priority:Success

Please check all that apply: o Pregnant o Pacemaker o Lymphedema o Infection of skin; location: ___________

ALLERGIES

Medications

Supplements/Foods

Reaction

Reaction

EMOTIONS AND SLEEP

How do you feel emotionally? __________________________________________________________________

Are you: o Married/Stable Relationship o Single o Widowed How do you feel about your relationship? _________

________________________________________________________________________________________________

How do you hold your stress? ________________________________________________________________________

How do you relax? ________________________________________________________________________________

How would you rate your stress level? (0 little or no stress to 10 high stress): ___________________________________

How long do you normally sleep? ________ Hours a night Do you feel rested upon waking? Yes No

Do you have any of the following (please check all that apply)

Overall Temperature (KI FXN)o Cold Hands o Cold Feet o Sweaty Hands o Sweaty Feeto Hot Body Temperature (sensation) o Cold Body Temperature (sensation) o Afternoon Flusheso Night Sweats o Heat in the hands, feet and chest o Hot flashes any time of the day

o Thirstyo Perspire Easilyo Lack of Perspiration o Take water to bedo Difficulty keeping eyes open in the daytime

Overall Energyo Shortness of Breatho Difficulty keeping eyes open in

the daytime o General Weakness o Easily Catch Coldso Feel worse after exercise

Blood (Liv, SP, HT Fxn)o Dizzinesso See Floating Black Spots

LU Fxno Nasal Discharage (Color: _______ )o Cough o Nose Bleedso Sinus Congestiono Dry Moutho Dry Nose o Dry Throat o Dry Skin o Allergies (to what? ____________ )o Alternating Fevers and Chillso Sneezing o Headache (location: ___________ )o Overall achy feeling in the bodyo Stiff Necko Stiff Shoulderso Sore Throat o Difficulty Breathing

o Smoke Cigarettes (# per day: ____ )o Sadnesso MelancholySP Fxn

o Low Appetiteo Abrupt Weight Gain o Abrupt Weight Losso Abdominal Bloatingo Abdominal Gaso Gurgling Noise in the Stomach o Fatigue After Eating o Prolapsed Organs (organ: _______ ) o Easily Bruisedo Hemorrhoidso Pensive/Reflective/Daydreaming

o Overthinkingo Worry

SP, ST, LI, SI Fxno Loose Stoolo Constipation o Incomplete Bowel Movementso Diarrheao Blood in Stoolo Mucous in Stoolo Undigested Food in Stool o General sensation of heaviness in the bodyo Mental Sluggishnesso Mental Fogginesso Swollen Hands o Swollen Feeto Swollen Jointso Chest Congestiono Stiff Shoulderso Nauseao Snoring

ST Fxno Burning sensation after eatingo Large Appetite o Bad Breatho Mouth (canker) soreso Bleeding, swollen or painful gumso Heartburno Acid regurgitation o Ulcer (diagnosed)o Belchingo Hiccupso Stomach Pain o Vomiting

Please check all current symptoms occurring or present in the past 6 months

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HT Fxno Palpitations o Anxiety o Sores on the tip of the tongueo Restlessnesso Mental Confusion o Chest pain traveling to shouldero Frequent Dreamso Wake Unrefreshed o Drink Coffee (# of cups per day)

Eyes (LIV Fxn)o Itchyo Bloodshot o Hoto Dryo Watery o Grittyo Blurred Visiono Decreased Night Vision o Near-sightedo Far-sighted

Women Onlyo Regular Cycle Yes No o Date of last period: __________ o Infertility? Yes Noo Number of children: ______o Age of first menstruation: ______

o Average # of days of flow: ______

o Average # of days of cycle: _____o Pregnant? Yes No o Number of pregnancies: ______ o Number of miscarriages: ______ o Number of abortions: _______ o Age of menopause: _______ Vaginal discharge: o Severe o Moderate o Slight o NormalMenstrual bleeing: o Severe o Moderate o Slight o Normal o Clots o SpottingColor of menses: ________________o Irregular menstruationo Vaginal itching/burning o Uterine fibroids

o Birth control use? What type?______________________________Do you experience any of the following PMS symptoms? o Nausea o Headaches o Migraines o Anxiety o Food cravings o Irritability o Breast swelling o Breast tenderness o Depression o Bloating o Vomiting o Dull pain, where? ___________ o Sharp pain, where? __________ o Pain before period o Pain during period o Pain after period

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LIV, GB Fxno Alternating loose and hard stoolo Chest Pain o Tight sensation in chesto Bitter taste in moutho Anger Easily o Frustrationo Depressiono Irritability o Frequent inability to adapt to stress o Skin rashes o Headaches at the top of the head o Tingling sensationo Numbnesso Muscle Spasms o Muscle Twitchingo Muscle Crampingo Seizures o Convulsionso Lump in throato Neck Tension o Limited range of motion, necko Shoulder Tensiono Limited range of motion, shouldero Drink Alcoholo Recreational Drugso High pitched ringing in the ears o Gall Stoneso Sexually transmitted disease

KI, UB Fxno Frequent cavitieso Easily broken bones o Sore kneeso Weak kneeso Cold sensation in the kneeso Low back paino Poor memoryo Excessive hair loss o Low-pitched ringing in the ears o Kidney stones o Bladder infections o Frequent night time urinationo Lack of bladder controlo Fearo Easily startled

Urinationo Normal coloro Dark yellow o Clearo Reddisho Cloudyo Scantyo Profuseo Strong odor o Burning o Painful o Difficult

o Urgento Frequent

Libidoo Normalo Higho Low

Men Onlyo Swollen Testes o Testicular Paino Impotence o Premature ejaculationo Feeling of cold or numb in testicles

Overall Temperature (KI Fxn)o Cold Handso Cold Feeto Sweaty Handso Sweaty Feeto Hot body temperatureo Cold body temperatureo Afternoon flushes

o Night sweatso Heat in the hands, feet and chest

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PLEASE COMPLETE IF YOU ARE SEEKING TREATMENT FOR PAIN:

Please describe your pain level 0 no pain at all to 10 being the worst

0........1........2........3........4........5........6........7........8........9........10

Do any of the following lessen the pain?

o Pressure o Cold o Heat o Exercise o Other: _______________

Do any of the following worsen the pain?

o Pressure o Cold o Heat o Exercise o Other: _______________ Location of pain: ___________________________________________________________________

How long have you had pain? ______ years _____ months _____ days

How often are you experiencing pain?

What makes the pain worse? __________________________________________________________

Pain character: o Dull o Sharp o Cramping o Burning o Radiating o Ache

o Moves o Numb o Tingling

When did pain begin? _________________________________________________________________

Was pain caused by an injury? o Yes: _____________________________________ o No

Prior treatment: o Medication o Blocks/Injections o Surgery o PT

o Chiropractor o Massage o Other

o No pain

D - Dull S - Sharp C - Cramping B - BurningR - Radiating M - Moves About N - Numbness T - Tingling

X - Scars from injury or surgery A - Acne O - Rashes, Skin Disorders Other

Using the letters at the bottom of the page to describe your pain, indicate on the figures

the area(s) where you are experiencing pain.

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Page 7

For Patient Review Regarding Diagnostic Exam Please sign one of the two options below:

Option 1

I have received a diagnostic exam by a physician or chiropractor within the last six months regarding the condition for which I am seeking treatment.

____________________________________________________________________________________Patient Signature Date

Option 2

I have NOT received a diagnostic exam by a physician or a chiropractor within the last six months re-garding the condition for which I am seeking treatment. Ohio law requires that a Licensed Acupuncturist recommend that you receive a diagnostic examination from a physician or a chiropractor regarding the condition for which you are seeking treatment.

I understand this recommendation.

____________________________________________________________________________________Patient Signature Date

____________________________________________________________________________________Licensed Acupuncturist Signature Date

cc: Patient file, Copy to patient

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I, __________________________, seek and consent to the services of Tamara Macdonald, ND

to provide supportive, naturopathic care for myself or my minor child or children. Naturopathic

services use natural means and remedies to further health and wellness, including assessment

and patient education and counseling about nutritional interventions; herbal and homeopathic

remedies;; lifestyle modifications and a range of other natural interventions/consultation.

Non-Medical and Complementary Nature of Services

I understand that Tamara Macdonald, ND is not a medical doctor and that naturopathy is not

a medical specialty but a separate and distinct health care tradition. I understand that Tamara

Macdonald, ND is a licensed, board-­certified naturopathic physician in the State of Washington, based upon her four-year graduate training in an accredited institution as a naturopathic

physician. Naturopathic physicians are licensed in 17 states, and in the District of Columbia, but

the State of Ohio does not currently offer such licensing. Where naturopathic physicians are not licensed, their scope of practice does not encompass the diagnosis and treatment of disease, but

is focused upon consultations regarding natural remedies. Tamara Macdonald’s consultations

include discussion of nutritional issues and of diet, nutrition and supplementation, such as the use

of dietary supplements and botanical substances; homeopathic remedies; mind-body supportive

counseling; promotion of healthy lifestyles and wellness.

Tamara Macdonald’s work in Ohio does not allow her to offer the full range of services within her training, but the educational consultations she provides are at the core of the naturopathic

approach to health. I understand that her assessments and recommendations are intended to

assist me in using natural means to support my health and are not intended to provide medical

diagnosis or treatment. I should not avoid any diagnostic work-ups or change or discontinue any

medical treatment based upon my consultation with Tamara Macdonald, and if I believe that

modifications may be sensible in light of these natural approaches, I agree to first discuss such changes with my prescribing medical physician.

If I believe that I have a condition that requires medical care, I will consult my primary care

physician or an appropriate specialist. It is important that I maintain regular visits with my

primary care physician and medical specialists as appropriate, both to ensure proper medical care

and because Tamara Macdonald, ND is not affiliated with a local hospital and I should have a medical physician who can provide care in the event of an emergency or hospitalization. When appropriate, Tamara Macdonald may communicate with members of my health team regarding

my conditions, treatment options, and/or any other health related issues. I agree to follow-up on referrals for medical care when necessary.

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Naturopathic practice uses methods that are known as complementary, alternative, or holistic

care, and may not be accepted by the larger community of medical physicians. Tamara

Macdonald, ND may suggest laboratory tests, some of which are used by holistic physicians

and naturopathic practitioners but which are not in widespread use in the medical community.

Further, the interpretation of some tests may be different than in mainstream medicine. It is a

good idea for me to get the advice of my medical physician as I make decisions that affect my

health.

Tamara Macdonald, ND will explain her assessment to me and describe the nature of her

recommendations, the expected prognosis without such care, and the anticipated costs, risks,

benefits and experience of following various options. I understand that a core approach taken by naturopathy is achieving better health status through improvements in diet and the use of dietary

supplements to improve biological function, as well as exercise and other lifestyle modifications. The focus of naturopathic care is to alleviate the underlying conditions that can bring about

illness rather than the treatment of symptoms. While I may experience some immediate improvement from the use of herbs, homeopathic remedies and other botanical and naturopathic

methods, I understand that the most effective results occur when I make a long-term commitment

to rebuild my health. It is my responsibility as a patient to follow-up with Tamara Macdonald

within a recommended time period for evaluation of treatment results or to change treatment

protocols as necessary.

I understand that Tamara Macdonald, ND does not offer after hour services or provide any

hospital-­based services. If I have difficulty with any of remedies or other aspects of my work with Tamara Macdonald, I understand I should call during business hours to discuss concerns I

may have.

Potential Risks: As with any method of care, naturopathy can involve some risk. I understand

that I may experience aches, pains, or even new symptoms as the body responds by shifting its

balance. This is generally a positive sign and shows the body is making positive movement.

Some people may experience a healing crisis, a short period in which symptoms worsen or a period of a flu-­like illness with mild fever, chills, dizziness, loss of appetite, or similar symptoms. Such an experience can signal the body is detoxifying.

While herbs and botanical products are generally available over-­the-­counter and are considered safe based upon their long history of use, many of them have not been widely tested. Negative

reactions to natural remedies may include rare allergic reactions, including headaches, itching,

hives, difficulty breathing, and very rarely, even shock or death. I understand that the interactions between herbs, and between herbs and drugs my medical physician might prescribe, are not yet

North Coast Natural Health and Acupuncture Clinic

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well known, and that while unlikely, I could have an adverse reaction or experience a reduction

or increase in the effect of other medications. This can have serious consequences for some

medications, such as for the control of high blood pressure or blood sugar. I understand that

I should let my physician know what herbs I am taking, particularly prior to surgery or other

procedures. Negative reactions to homeopathy are extremely rare given the doses used; an

effective dose may result in a temporary increase in my symptoms or healing crisis. I understand

that it is my responsibility to alert Tamara Macdonald of any adverse effects or reactions.

Notice to Pregnant Women: All female clients must alert Tamara Macdonald, ND if they know

or suspect that they are pregnant as some of the remedies used could present a risk.

No Guarantees: I am aware that such consultations are an art, that like many medical

interventions, many naturopathic efforts have not been subjected to rigorous scientific study, and that there are wide individual differences in responses to these services. No guarantees are made

that I will gain any benefit or not suffer any adverse consequences. In the event that a dispute arises that we cannot resolve amicably, I understand that Tamara Macdonald is not practicing

medicine and that if a legal case is brought, I agree that Tamara Macdonald shall be judged

by the standards and principles of complementary, alternative, and/or holistic care and not the standards of consensus conventional medicine.

Supplement Purchases: I understand I am not obligated to purchase nutritional or herbal

products recommended by Tamara Macdonald, from this office or from any specific vendor, and I will be given the same level of attention without regard to my purchases. I understand

that Tamara Macdonald, ND may profit from the sale of supplements and other products made available to patients.

Privacy Policy: My privacy is important and my records will be held confidential unless I request in writing that they be released to me or to other care givers. The HIPAA privacy

regulations I have seen in other offices do not apply to Tamara Macdonald, ND as she does not submit claims to insurers, which must be done electronically before HIPAA regulations apply.

Important Insurance and Payment Notices: Tamara Macdonald’s services are, with few

exceptions, not reimbursed by insurance or Medicare and she does not accept insurance.

Insurance generally provides services only when delivered by individuals licensed to provide

health care services in the state in which care is delivered.

Cancellation Policy: Dr.. Macdonald requires that cancellations for scheduled appointments be

received 24 hours in advance during regular office hours (Monday—Friday, 9 a.m.—5 p.m.). We

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reserve the right to charge for missed or cancelled appointments that do not follow this policy. Fees

are based on a rate of $145 per hour.

Tamara Macdonald, ND is therefore unable to accept insurance payment and does not provide billing statements for insurance reimbursement. Payment in full is required at each visit. I understand I am responsible for payment even if I submit and am denied reimbursement, even if my insurer determines that services are not medically necessary. I understand that appointments can be made by phone or in person. Tamara Macdonald requests 24-hours notice for canceling or rescheduling appointments. For any visits canceled with less than 24-hours notice, the patient will be charged half of the original visit fee except in the case of family or medical emergency. This charge will be applied to the following visit or billed directly to the client. Late arrivals will not receive an extension of scheduled service times and will be responsible for full service fee. In the event legal action is required to collect payment, I agree to be responsible for attorney fees and costs.

Informed Consent for Naturopathic Consultation

I hereby authorize naturopathic assessment and consultation and certify that I understand the

nature of this health care method, including the risks of possible adverse reactions and choices I

may have about other approaches. I understand that no recommendations are being made to me

to discontinue any treatment being provided by any other health care professional. I understand

that Tamara Macdonald, ND does not function as a primary care or medical physician, and

that she offers her services as a complement to other services I receive. I have been adequately

informed, and questions I have asked have been satisfactorily answered. I represent that I am

seeking assessment and consultation in order to further my own health and for no other reason

and do not represent a third party. I sign this voluntarily and am aware that I may withdraw this

consent and discontinue following the recommendations at any time.

______________

Date

_____________________________________

Signature of Client or Legal Guardian Witness

___________________________________

Client's Printed Name

North Coast Natural Health and Acupuncture Clinic

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HIPAA PRIVACY NOTICEEffective date of this notice: June 21, 2013

PLEASE REVIEW THIS NOTICE CAREFULLY. IT DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU MAY GAIN ACCESS TO THAT INFORMATION.

POLICY STATEMENT

Tamara Macdonald, ND is committed to maintaining the privacy of your protected health

information ("PHI"), which includes information about your medical condition and the care and treatment you receive from Tamara Macdonald ND, and other health care providers. This

Notice details how your PHI may be used and disclosed to third parties for purposes of your care,

payment for your care, health care operations of North Coast Natural Health & Acupuncture, and

for other purposes permitted or required by law. This Notice also details your rights regarding

your PHI.

USE OR DISCLOSURE OF PHI

We may use and/or disclose your PHI for purposes related to your care, payment for your care, and health care operations of North Coast Natural Health & Acupuncture. The following are

examples of the types of uses and/or disclosures of your PHI that may occur. These examples are not meant to include all possible types of use and/or disclosure.

Care – In order to provide care to you, we will provide your PHI to those health care

professionals directly involved in your care so they may understand your medical condition and

needs and provide advice or treatment. For example, another physician may need to know how

your condition is responding to the treatment provided by Tamara Macdonald, ND, LAc.

Payment – In order to get paid for some or all of the health care provided by Tamara

Macdonald, ND, LAc, we may provide your PHI, directly or through a billing service, to appropriate third party payers, pursuant to their billing and payment requirements. For

example, we may need to provide your health insurance carrier with information about health

care services you received from us so we may be properly reimbursed.

Health Care Operations – In order for us to operate in accordance with applicable law and

insurance requirements and in order for us to provide quality and efficient care, it may be necessary for Tamara Macdonald ND, LAc to compile, use and/or disclose your PHI. For example, we may use your PHI in order to evaluate the performance of our personnel in

providing care to you.

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AUTHORIZATION NOT REQUIRED

We may use and/or disclose your PHI, without a written Authorization from you, in the following instances:

De-­identified Information1. – Your PHI is altered so that it does not identify you and, even

without your name, cannot be used to identify you.

Business Associate 2. – To a business associate, who is someone we contract with to provide

a service necessary for your treatment, payment for your treatment and/or health care operations (e.g., billing service or transcription service). We will obtain satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately

safeguard your PHI.

Personal Representative3. – To a person who, under applicable law, has the authority to

represent you in making decisions related to your health care.

Public Health Activities 4. – Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent or control disease, injury or

disability. This includes reports of child abuse or neglect.

Federal Drug Administration5. – If required by the Food and Drug Administration to report

adverse events, product defects, problems, biological product deviations, or to track products,

enable product recalls, repairs or replacements, or to conduct post marketing surveillance.

Abuse, Neglect or Domestic Violence6. – To a government authority, if we are required by law

to make such disclosure. If Tamara Macdonald, ND, LAc is authorized by law to make such a disclosure, we will do so if we believe the disclosure is necessary to prevent serious harm

or if we believe you have been the victim of abuse, neglect or domestic violence. Any such

disclosure will be made in accordance with the requirements of law, which may also involve

notice to you of the disclosure.

Health Oversight Activities7. – Such activities, which must be required by law, involve government agencies involved in oversight activities that relate to the health care system,

government benefit programs, government regulatory programs and civil rights law. Those activities include, for example, criminal investigations, audits, disciplinary actions, or general

oversight activities relating to the community's health care system.

Judicial and Administrative Proceeding8. – For example, we may be required to disclose your

PHI in response to a court order or a lawfully issued subpoena.

Law Enforcement Purposes9. – In certain instances, your PHI may have to be disclosed to a

law enforcement official for law enforcement purposes. Law enforcement purposes include: (1) complying with a legal process (i.e., subpoena) or as required by law;; (2) information for identification and location purposes (e.g., suspect or missing person);; (3) information regarding a person who is or is suspected to be a crime victim;; (4) in situations where the death of an individual may have resulted from criminal conduct;; (5) in the event of a crime

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occurring on the premises of North Coast Natural Health & Acupuncture;; and (6) a medical 1.

emergency (not on our premises) has occurred, and it appears that a crime has occurred.

Coroner or Medical Examiner2. – We may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death, or to a funeral director

as permitted by law and as necessary to carry out its duties.

Organ, Eye or Tissue Donation3. – If you are an organ donor, we may disclose your PHI to the

entity to whom you have agreed to donate your organs.

Research4. – If we are involved in research activities, your PHI may be used, but such use is

subject to numerous governmental requirements intended to protect the privacy of your PHI

such as approval of the research by an institutional review board, the de-­identification of your PHI before it is used, and the requirement that protocols must be followed.

Avert a Threat to Health or Safety5. – We may disclose your PHI if we believe that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or

safety of a person or the public and the disclosure is to an individual who is reasonably able

to prevent or lessen the threat.

Specialized Government Functions6. – When the appropriate conditions apply, we may use PHI of individuals who are Armed Forces personnel: (1) for activities deemed necessary by appropriate military command authorities;; (2) for the purpose of a determination by the Department of Veteran Affairs of eligibility for benefits;; or (3) to a foreign military authority if you are a member of that foreign military service. We may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities including the provision of protective services to the President or others legally authorized.

Inmates7. – We may disclose your PHI to a correctional institution or a law enforcement official if you are an inmate of that correctional facility and your PHI is necessary to provide care and treatment to you or is necessary for the health and safety of other individuals or

inmates.

Workers' Compensation8. – If you are involved in a Workers' Compensation claim, we may be required to disclose your PHI to an individual or entity that is part of the Workers' Compensation system.

Disaster Relief Efforts9. – We may use or disclose your PHI to a public or private entity authorized to assist in disaster relief efforts.

Required by Law10. – If otherwise required by law, but such use or disclosure will be made in

compliance with the law and limited to the requirements of the law.

AUTHORIZATION

Uses and/or disclosures, other than those described above, will be made only with your written Authorization, which you may revoke at any time.

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APPOINTMENT REMINDER

We may, from time to time, contact you to provide appointment reminders. We will try to minimize the amount of information contained in the reminder. We may contact you by phone and, if you are not available, we will leave a message for you. Please note that we will use the

contact information that you have provided us to call with appointment reminders.

TREATMENT ALTERNATIVES/BENEFITS

We may, from time to time, contact you about treatment alternatives we offer, or other health benefits or services that may be of interest to you.

YOUR RIGHTS

You have the right to:

Revoke any Authorization, in writing, at any time. To request a revocation, you must • submit a written request to our Privacy Officer.

Request restrictions on certain use and/or disclosure of your PHI as provided by • law. However, we are not obligated to agree to any requested restrictions. To request

restrictions, you must submit a written request to our Privacy Officer. In your written request, you must inform us of what information you want to limit, whether you want to

limit Tamara Macdonald ND, LAc use or disclosure, or both, and to whom you want the limits to apply. If we agree to your request, we will comply with your request unless the

information is needed in order to provide you with emergency treatment.

Receive confidential communications of PHI by alternative means or at alternative • locations. You must make your request in writing to our Privacy Officer. We will accommodate all reasonable requests.

Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you must • submit a written request to our Privacy Officer. In certain situations that are defined by law, we may deny your request, but you will have the right to have the denial reviewed.

We may charge you a fee for the cost of copying, mailing or other supplies associated with your request.

Amend your PHI as provided by law. To request an amendment, you must submit a • written request to our Privacy Officer. You must provide a reason that supports your request. We may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by Tamara

Macdonald ND, LAc (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by Tamara Macdonald ND, LAc, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with our denial, you have the right to submit a written statement of

disagreement.

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Receive an accounting of non-routine disclosures of your PHI as provided by law. To • request an accounting, you must submit a written request to our Privacy Officer. The request must state a time period which may not be longer than six years and may not

include the dates before September 17, 2007. The request should indicate in what form you want the list (such as a paper or electronic copy). The first list you request within a 12 month period will be free, but we may charge you for the cost of providing additional

lists in that same 12 month period. We will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred.

Receive a paper copy of this Privacy Notice from us upon request.•

To file a complaint with Tamara Macdonald, ND, LAc, please contact our Privacy Officer. • All complaints must be in writing.

If your complaint is not satisfactorily resolved, you may file a complaint with the • Secretary of Health and Human Services, Office for Civil Rights. Our Privacy Officer will furnish you with the address upon request.

To obtain more information, or have your questions about your rights answered, please • contact our Privacy Officer.

OUR RESPONSIBILITIES

This office:

Is required by law to maintain the privacy of your PHI and to provide you with this • Privacy Notice upon request.

Is required to abide by the terms of this Privacy Notice.•

Reserves the right to change the terms of this Privacy Notice and to make the new • Privacy Notice provisions effective for all of your PHI that we maintain.

Will not retaliate against you for making a complaint.•

Must make a good faith effort to obtain from you an acknowledgement of receipt of this • Notice.

Will post this Privacy Notice in our lobby and on our web sites at • www.northcoastnaturalhealth.com