This office/practice is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about your health condition and the health care you receive from the practice. The creation of a record detailing the care and services you receive helps this office to provide you with quality health care. This notice details how your PHI may be used and disclosed to third parties. This notice also details your rights regarding your PHI.
The office/practice may use and/or disclose your PHI for the following purposes:
Health care: In order to provide you with the health care you require, the office/practice will provide your PHI to those health care professionals, whether on the practice’s staff or not, directly involved in your care so that they may understand your health condition and needs. For example, a chiropractor adjusting you for a subluxation of the cervical spine may need to know the results of your latest chiropractic examination by this office.
Payment: In order to get paid for services provided to you, the office/practice will provide your PHI, directly or through a billing service, to appropriate third payer payers, pursuant to their billing and payment requirements. For example, the practice may need to provide the Medicare program with information about health care services that you received from the practice so that the practice, or you, can be properly reimbursed. The practice may also need to tell your insurance plan about the care you are going to receive so that it can determine whether or not it will cover the health care expenses
Health Care Operations: In order for the office/practice to operate in accordance with applicable law and insurance requirements and in order to continue to provide quality and efficient care, it may be necessary for the practice to compile, use, and/or disclose your PHI. For example, the practice may use your PHI in order to evaluate the performance of the practice’s personnel in providing care to you.
The office/practice may also use and/or disclose your PHI without your specific authorization for the following additional instances:
De-identified Information: Information that does not identify you and, even without your name, cannot be used to identify you.
Business Associates: To a business associate if the office/practice obtains satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI. A business associate is an entity that assists the practice in undertaking some essential function, such as a billing company that assists the office in submitting claims for payment to insurance companies or other payers.
Personal Representative: To a person who, under applicable law, has the authority to represent you in making decisions related to your health.
Emergency Situations: For the purpose of obtaining or rendering emergency treatment to you if the opportunity for you to object cannot be obtained due to your incapacity or emergent treatment circumstances and the treatment circumstances and the treatment is consistent with your prior expressed preferences and is in your best interest or
To a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating your care with such entities in an emergency situation.
Public Health Activities: Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent serious harm.
Abuse, Neglect, or Domestic Violence: To a government authority in the office/practice is required by law to make such disclosure. If the practice is authorized by law to make such a disclosure, it will do so if it believes that the disclosure is necessary to prevent serious harm.
Health Oversight Activities: Such activities, which must be required by law, involve government agencies and may include for example, criminal investigations, disciplinary actions, or general oversight activities relating to the community’s health care system.
Law Enforcement Purpose: In certain instances, your PHI may have to be disclosed to a law enforcement official. For example, your PHI may be the subject of a grand jury subpoena. Or, the practice believes your death was the result of criminal conduct.
Coroner or Medical Examiner: The office/practice may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death.
Organ, eye, or tissue donation: If you are an organ donor, the practice may disclose your PHI to the entity to whom you have agreed to donate your organs.
Research: If the office/practice is 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.
Avert a threat to health or safety: The office/practice may disclose your PHI if it believes disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and disclosure is to an individual who is reasonable able to prevent or lessen the activity.
Specialized Government Function: This refers to disclosures of PHI that relate primarily to military and veterans activity.
Workers Compensation: If you are involved in a Worker’s Compensation claim, the office/practice may be required to disclose your PHI to an individual or entity that is part of the Worker’s Compensation System.
National Security and Intelligence Activities: The office/practice may disclose your PHI in order to provide authorized governmental officials with necessary intelligence information for national security activities and purpose authorized by law.
Military and Veterans: If you are a member of the armed forces, the office/practice may disclose your PHI as required by the military command authorities
Fundraising: In order to conduct or assist business associates and/or other institutionally related foundations raise funds for a charitable purpose, such as local hospital, the American Red Cross, or other private or public disaster relief agencies, Breast Cancer or AIDS-related research, etc., this office/practice may give out demographic information about you as well as any dates health care was provided to you without your specific authorization. However, if this office/practice does engage in any fundraising activity, it must include instructions on how you may decline to receive further fundraising communications from the office/practice.
Appointment Reminder: The office/practice may, from time to time, contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. The following appointment reminders are used by the practice: postcard, letter, and telephone.
Directory/Sign-in Log: The office/practice maintains a directory of and sign-in log for individuals seeking care and treatment in the office. Directory and sign-in log are located in a position where staff can readily see who is seeking care in the office, as well as the individuals located within the practice’s office suite. This information may be seen by, and is accessible to, others who are seeking care or services in the practice’s office.
Family and Friends: The office/practice may disclose to your family member, other relative, a close personal friend, or any other person identified by you, your PHI directly relevant to such person’s involvement with your care or the payment of your care. The practice may also use or disclose your PHI to notify or assist in the notification (including identifying or location) a family member, a personal representative, or another person responsible for your care, of your location, general condition, or death. However, in both cases, the following conditions will apply:
(a) If you are present at or prior to the use or disclosure of your PHI, the office/practice may use or disclose your PHI if you agree, or the practice can reasonably infer from the circumstances, based on the exercise of its professional judgement that you do not object to the use or disclosure.
(b) If you are not present, the office/practice will in the exercise of professional judgement, determine whether the use or disclosure is in your best interests, and, if so, disclose only the PHI that is directly relevant to the person’s involvement with your care.
Authorization: Uses and/or disclosures, other than those described above will be made only with your written authorization.
Your rights: You have the right to:
(a) Revoke any authorization in writing, at any time.
(b) Request restrictions on certain use and/or disclosure of your PHI as provided by law. However, the office/practice is not obligated to agree to any requested restrictions.
(c) Inspect and copy your PHI by alternative means or at alternative locations. The practice will accommodate all reasonable requests.
(d) Inspect and copy your PHI as provided by law. The practice can charge you a fee for the cost of copying, mailing, or other supplies associated with your request. In certain situations that are defined by law, the practice may deny your request, but you will have the right to have the denial reviewed as set forth more fully in the written denial notice.
(e) Amend your PHI as provided by law. The request an amendment, you must submit a written request to the Practice’s Privacy Officer. You must provide a reason that supports your request. The practice 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 is not part of your PHI maintained by the practice, if the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with the practice’s denial, you will have the right to submit a written statement of the disagreement.
(f) Receive an accounting of disclosures of your PHI as provided by law. To request an accounting you must submit a written request to the Practice’s Privacy Officer. The request must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. The request should indicate in what form you want the list. The first list you request within a twelve-month period will be free, but the practice may charge you for the cost of providing additional lists. The practice will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred.
(g) Receive a paper copy of this Privacy Notice from the office/practice upon the request.
(h) Complain to the office/practice or to the Secretary of HHS if you believe your privacy rights have been violated. To file a complaint with the office/practice, you must contact the practice’s Privacy Officer. All complaints must be in writing.
(a) Is required by federal law to maintain the privacy notice detailing the practice’s legal duties and privacy practices with respect to your PHI.
(b) Is required by State Law to maintain a higher level of confidentiality with respect to certain portions of your medical information that is provided for under federal law.
(c) Is required to abide by the terms of this privacy notice.
(d) Reserves the right to change the terms of this privacy notice and to make the new privacy notice provisions effective for all your PHI that it maintains.
(e) Will distribute any revised privacy notice to you prior to implementation.
(f) Will not retaliate against you for filing a complaint.
This notice is in effect as of March 25, 2003.