The heart and soul of my Naturopathic care is centered on having a great connection with my patients, getting to know my patients as persons and recognizing their individuality, empowering my patients to make informed decisions about their health, assisting my patients to find the underlying causes of their health concerns, removing their obstacles to optimal wellness, promoting their body’s innate healing ability, and recommending safe and effective personalized natural therapeutics to achieve their optimal health and vitality.

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Effective Date: March 1st, 2019


In this document, “Dr. Kan Wellness Center, LLC” is also referred to as “the Wellness Center”.


If you have any questions about this notice, please contact Dr. Teerawong Kasiolarn by calling at 571-207-6768 or emailing at

Each time you visit a hospital, physician, or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information. This information is considered Protected Health Information (PHI). The Health Insurance Portability and Accountability Act (HIPAA) requires that we provide you with a notice regarding how your PHI may be used or disclosed and your rights concerning that information.  This notice applies to all of the records of your care generated by and as part of the care furnished to you at the Wellness Center. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s office or clinic.

Dr. Kan Wellness Center, LLC’s Responsibilities

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all PHI that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised copy by accessing our web site at and requesting that a revised copy be sent to you via email.  If any major change is made to this Notice, it will automatically be provided to you at the time of your next visit at the Wellness Center.

Uses and Disclosures

How we may use and disclose Medical Information about you.

The following categories describe examples of the way we use and disclose medical information:

For Treatment: We may use medical information about you to provide you treatment or services. For example, we may provide a physician or a hospital with information regarding your prior treatment at the Wellness Center if it might have bearing on the current condition for which you are being treated. We may disclose medical information about you to people outside of the Wellness Center who provide services that are related to your care.

We may also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you.

Payment: Your PHI will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services.  We recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.  Dr. Kan Wellness Center, LLC is a cash-based clinic practice and does NOT bill any health insurances for any of our services, and the all the necessary payments for our clinic services are due at the time of booking or scheduling our clinic appointments.  After finishing your visit at the Wellness Center, upon your request, we can provide you with the documentation (sometimes known as a “superbill”) needed to submit the fees to your health insurance for possible reimbursement.  Also, in the case that your health insurance does not cover our services, upon your request, we can provide you with the superbill document(s) to submit to your Flexible Spending Account (FSA) or Health Savings Account (HSA). The Wellness Center does not guarantee of any reimbursements of our clinic services from your health insurance, FSA, or HSA.

Health Care Operations: We may use or disclose your PHI in order to support the business activities of the Wellness Center. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conducting or arranging for other business activities.

For example, we may disclose your PHI to medical school students that see patients at the Wellness Center. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your provider. We may also call you by name in the waiting room when we are ready to assist you. We may use or disclose your PHI as necessary to contact you to remind you of your appointment or changes in our clinic services and policies.

We may use or disclose your PHI as necessary to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your PHI for other marketing activities. For example, your name and address may be used to send you a newsletter about the services we offer or to send you information about products or services that we believe may be beneficial to you. These activities are not considered to be marketing under the HIPAA Privacy Rule.

Use of your PHI for activities that would be considered marketing or disclosures that would constitute the sale of PHI may not be made without a signed authorization from you.

If you do not want to receive the materials described above, please contact Dr. Teerawong Kasiolarn directly at 571-207-6768 or by email at and request that these marketing materials not be sent to you.

Business Associates: Some of the services provided by the Wellness Center are provided through contracts with business associates. Examples may include information technology companies or outside billing services with which we contract. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information. The Wellness Center’s requirements for safeguarding your information are included in Business Associate Agreements with each such entity. In addition, all business associates are subject to oversight by the Secretary of Health and Human Services (HHS) and must adhere to all requirements of the HIPAA Privacy and Security Rules.

Individuals Involved in Your Care or Payment for Your Care: We may release medical information about you to a friend or family member who is involved in your medical care or who helps pay for your care. In addition, we may disclose medical 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. If you desire to limit disclosure of such information to friends or family members, we will ask that you designate one individual to whom we may make such disclosures. It will then be up to you to instruct that individual as to how they may disseminate information about you to other interested parties.

Research: Your medical information may be used or disclosed for research purposes without your permission if an Institutional Review Board (IRB) approves such use or disclosure. We may disclose medical information about you to researchers preparing to conduct a research project. In addition, researchers may contact you directly about participation in a study. The researcher will inform you about the study and give you an opportunity to ask questions. You will be enrolled in a study only after you agreed and signed a consent form indicating your willingness to participate in the study.

Future Communications: We may communicate to you via newsletters, emails, telephones, mailings or other means regarding treatment options, health related information, disease management programs, wellness programs, or other community based initiatives or activities in which our facilities are participating.

Health Information Exchange:  We may make your protected health information available electronically through an information exchange service to other health care providers that request your information. Participation in information exchange services also lets us see health care information about you from other health care providers who participate in the exchange.

As required by law, we may also use and disclose health information for the following types of entities, including but not limited to:

  • Food and Drug Administration (FDA)
  • Public Health or legal authorities charged with preventing or controlling disease, injury or disability
  • Correctional institutions
  • Workers Compensation agents
  • Organ and tissue donation organizations
  • Military command authorities
  • Health oversight agencies
  • Funeral directors, coroners and medical directors
  • National Security and Intelligence Agencies
  • Protective Services for the President and Others

Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes:

  • in response to a court order, subpoena, warrant, summons or similar process;
  • about a death we believe may be the result of criminal conduct;
  • about criminal conduct at the Wellness Center’s facility; and about wounds made by certain weapons.

State-Specific Requirements: Many states have requirements for reporting including population-based activities relating to improving health or reducing health care costs. Some states have separate privacy laws that may apply additional legal requirements. If the District of Columbia (DC) Law is more stringent than Federal privacy laws, DC law preempts the Federal law.

Uses or disclosures of your PHI not described in this notice will be made solely upon written authorization from you or your personal representative. Written authorizations may be revoked by contacting the department originally authorized to use/disclose the information.

Your Health Information Rights:

Although your health record is the physical property of the health care practitioner or facility that compiled it, you have the Right to:

  • Inspect and Copy: You have the right to inspect and copy medical information in our possession that may be used to make decisions about your care. As a rule, this includes medical and billing records, but does not include psychotherapy notes. You may request an electronic copy of your PHI maintained in the Wellness Center’s electronic health record (EHR).  Access to your records must be provided within 15 days of the receipt of your request. We may deny your request to inspect and copy your records in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. A licensed health care professional not involved in the original denial of your request will be chosen by the Wellness Center to review your request and the denial. We will comply with the outcome of the review.
  • Request an Amendment of Your Information: If you feel that your medical information we have on file is incorrect or incomplete, you may ask us to amend that information. You have the right to request an amendment for as long as the Wellness Center retains the information. We may deny your request for an amendment and, if this occurs, you will be notified of the reason for the denial and will be provided with your options as defined in the HIPAA Privacy Rule.
  • Request an Accounting of Disclosures: You have the right to request an accounting of any disclosures we make of your medical information for purposes other than treatment, payment or health care operations.
  • Right to Restrict Release of Information For Certain Services
  • You have the right to request a restriction on disclosure of health information about services you paid for out of pocket in full. This request should be made prior to the service being provided and applies only if the disclosure is to a health plan for purposes of payment or health care operations.
  • You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or

the payment for your care, like a family member or friend. For example, you could ask that we not disclose information about your Naturopathic treatments or services.

Restrictions should be requested in writing. 

  • With the exception of restrictions regarding services or procedures that you pay for out of pocket, we are not required to agree to your request. Requests for restrictions or limitations on the medical information we use or disclose about you for treatment, payment or health care operations must be forwarded to Dr. Teerawong Kasiolarn. Only Dr. Teerawong Kasiolarn or his/her designee can agree to such restrictions or limitations. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
  • Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we contact you at a location other than your home or by secure encrypted email system or by the U.S. mailing system. Such requests must be made in writing and must include a mailing address or the email address where bills for services and related correspondence regarding payment for services will be received. It is important that you note that the Wellness Center reserves the right to contact you by other means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.
  • Breach Notification: You have a right to be notified following a breach of your unsecured PHI.
  • A Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time, even if you have agreed to receive this notice electronically.

You may obtain a copy of this notice at our web site at 

To exercise any of your rights under this notice, please obtain the required forms from the Registration Department in the facility where you received your services and submit your request in writing. 


We reserve the right to change this notice at any time. The revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted on our website and will include the effective date.


If you believe your privacy rights have been violated, you may file a complaint with the

Wellness Center by contacting Dr. Teerawong Kasiolarn directly via phone at 571-207-6768, or email at All complaints must be submitted in writing. You will not be penalized for filing a complaint about the Wellness Center’s Privacy practices.


We are required to retain our records of the care that we provided to you. The Wellness Center will make other uses and disclosures of medical information not covered by this notice or the laws that apply to us only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If we receive written revocation of your permission, we will cease the use or disclose medical information you originally authorized. We would not be able to take back any disclosures we had already made with your permission.