HIPAA Compliant Authorization to Release Health Information
To Practice Members:
Federal law requires us to disclose our Privacy Practices to you. We trust that by taking a few moments to read our notice, you will have a better understanding of how we strive to protect the information you entrust to us.
Types of information we collect in the day-to-day operations of our chiropractic office, health care and related information such as your name, address, date of birth, medical history, diagnosis, treatment, health plan or payer information and financial responsibility are collected. This ‘personal health information’ (PHI), is also known as ‘protected health information’.
Confidentiality and security of your personal information: We restrict access to PHI to those who need the information to provide treatment, payment, or other health care operations to our patients. There are certain instances in which information may need to be disclosed even without prior permission from the patient. This would be for national priority purposes only: if required by law, public health activities, victims of abuse, neglect, or domestic violence, judicial and administrative proceedings, research, serious threats to health or safety, etc.
A complete chiropractic analysis and examination must be completed and additional steps may be needed to make the proper diagnosis. After collecting and using this personal information, it may be necessary to disclose certain information to other health care professionals or third-party participants. Your information is private and confidential and there are policies and procedures in place to protect the information against unlawful use and disclosure. Access to your PHI is restricted to only those employed by Clear Connections Chiropractic who needs it to provide services or benefits to our patients and their dependents.
If you wish to grant family or loved ones’ access to your health information, please indicate their information below.
Written or verbal information will be provided upon request only to those listed below.