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NOTICE OF PRIVACY
PRACTICES
This notice describes how medical
information about you may be used and disclosed and how you can get
access to this information. Please review it carefully.
If you have any questions about this Notice, please contact PATSY of
our office, who is our privacy contact.
This Notice of Privacy Practices describes how we may use and
disclose your protected health information to carry out your
treatment, collect payment for your care and manage the health care
operations of this office. It also describes our policies concerning
the use and disclosure of this information for other purposes that
are permitted or required by law. It also describes your rights to
access and control your protected health information. “Protected
health information” is information about you, including demographic
information that may identify you, that relates to your past,
present or future physical or mental health or condition and related
health care services.
We are required by federal law 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 protected health
information that we maintain at that time. You may obtain revisions
to our Notice of Privacy Practices by calling the office or
accessing our website and requesting that a revised copy be sent to
you in the mail or asking for one at the time of your next
appointment.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Uses and Disclosures of Protected Health Information Based Upon Your
Implied Consent
By applying to be treated in our office, you are implying consent to
the use and disclosure of your protected health information by your
physician, our office staff and others outside of our office that
are involved in your care and treatment for the purpose of providing
health care services to you. Your protected health information may
also be used and disclosed to bill for your health care and to
support the operation of the physician’s practice.
Following are examples of the types of uses and disclosures of your
protected health care information we will make, based on this
implied consent. These examples are not meant to be exhaustive but
to describe the types of uses and disclosures that may be made by
our office.
Treatment: We will use and disclose your protected health
information to provide, coordinate, or manage your health care and
any related services. This includes the coordination or management
of your health care with a third party that has already obtained
your permission to have access to your protected health information.
For example we would disclose your protected health information, as
necessary, to another physician who may be treating you. Your
protected health information may be provided to a physician to whom
you have been referred to ensure that the physician has the
necessary information to diagnose or treat you.
In addition, we may disclose your protected health information from
time-to-time to another physician or health care provider (e.g., a
specialist or laboratory) who, at the request of your physician,
becomes involved in your care by providing assistance with your
health care diagnosis or treatment to your physician.
Payment: Your protected health information 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 service provided to you for
medical necessity, and undertaking utilization review activities.
For example, obtaining approval for chiropractic care may require
that your relevant protected health information be disclosed to the
health plan to obtain approval for those services.
Healthcare Operations: We may use or disclose, as needed, your
protected health information in order to support the business
activities of your physician’s practice. These activities include,
but are not limited to, quality assessment activities, employee
review activities and conducting or arranging for other business
activities.
For example, we may use a sign-in sheet at the registration desk
where you will be asked to sign your name and indicate your
physician. Communications between you and the doctor or his
assistants or interns, etc., may be recorded to assist us in
accurately capturing your responses. We may also call you by name in
the waiting room when your physician is ready to see you. We may use
or disclose your protected health information, as necessary, to
contact you to remind you of your appointment.
We will share your protected health information with third party
“business associates” that perform various activities (e.g.,
billing, transcription services) for the practice. Whenever an
arrangement between our office and a business associate involves the
use or disclosure of your protected health information, we will have
a written contract with that business associate that contains terms
that will protect the privacy of your protected health information.
We may use or disclose your protected health information, 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 protected
health information for other marketing activities. For example, your
name and address may be used to send you a newsletter about our
practice and the services we offer. We may also send you information
about products or services that we believe may be beneficial to you.
You may contact our staff members to request that these materials
not be sent to you.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION THAT MAY BE
MADE WITH YOUR WRITTEN AUTHORIZATION
Other uses and disclosures of your protected health information will
be made only with your written authorization, unless otherwise
permitted or required by law as described below.
For example, with your written, signed authorization, we may make
communication with you to promote products or services that may not
be for the specific purpose providing treatment advice.
You may revoke any of these authorizations at any time, in writing,
except to the extent that your physician or the physician’s practice
has taken an action in reliance on the use or disclosure indicated
in the authorization.
OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE
WITH YOUR AUTHORIZATION OR OPPORTUNITY TO OBJECT
In the following instance where we may use and disclose your
protected health information, you have the opportunity to agree or
object to the use or disclosure of all or part of your protected
health information. If you are not present or able to agree or
object to the use or disclosure of the protected health information,
then your physician may, using professional judgment, determine
whether the disclosure is in your best interest. In this case, only
the protected health information that is relevant to your health
care will be disclosed.
Others Involved in Your Healthcare: Unless you object, we may
disclose to a member of your family, a relative, a close friend or
any other person you identify, your protected health information
that directly relates to that person’s involvement in your health
care. If you are unable to agree or object to such a disclosure, we
may disclose such information as necessary if we determine that it
is in your best interest based on our professional judgment. We may
use or disclose protected health information to notify or assist in
notifying a family member, personal representative or any other
person that is responsible for your care of your location, general
condition or death. Finally, we may use or disclose your protected
health information to an authorized public or private entity to
assist in disaster relief efforts and to coordinate uses and
disclosures to family or other individuals involved in your health
care.
OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE
WITHOUT YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT
We may use or disclose your protected health information in the
following situations without your consent or authorization. These
situations include:
Required by Law: We may use or disclose your protected health
information to the extent that the use or disclosure is required by
law. The use or disclosure will be made in compliance with the law
and will be limited to the relevant requirements of the law. You
will be notified, as required by law, of any such uses or
disclosures.
Health Oversight: We may disclose protected health information to a
health oversight agency for activities authorized by law, such as
audits, investigations, and inspections. Oversight agencies seeking
this information include government agencies that oversee the health
care system, government benefit programs, other government
regulatory programs and civil rights laws.
Legal Proceedings: We may disclose protected health information in
the course of any judicial or administrative proceeding, in response
to an order of a court or administrative tribunal (to the extent
such disclosure is expressly authorized), in certain conditions in
response to a subpoena, discovery request or other lawful process.
Research: We may disclose your protected health information to
researchers when an institutional review board has approved their
research and that review board has reviewed the research proposal
and established protocols to ensure the privacy of your protected
health information.
Required Uses and Disclosures: Under the law, we much make
disclosures to you and when required by the Secretary of the
Department of Health and Human Services to investigate or determine
our compliance with the requirements of Section 164.500 et. seq.
YOUR RIGHTS
Following is a statement of your rights with respect to your
protected health information and a brief description of how you may
exercise these rights.
You have the right to inspect and copy your protected health
information. This means you may inspect and obtain a copy of
protected health information about you that is contained in a
designated record set for as long as we maintain the protected
health information. A “designated record set” contains medical and
billing records and any other records that your physician and the
practice uses for making decisions about you.
Under federal law, however, you may not inspect or copy the
following records: psychotherapy notes, information compiled in
reasonable anticipation of, or use in, a civil, criminal, or
administrative action or proceeding, and protected health
information that is subject to law that prohibits access to
protected health information. Depending on the circumstances, a
decision to deny access may be reviewable. In some circumstances,
you may have a right to have this decision reviewed. Please contact
our staff members if you have questions about access to your medical
record.
You have the right to request a restriction of your protected health
information. This means you may ask us not to use or disclose any
part of your protected health information for the purposes of
treatment, payment or health care operations. You may also request
that any part of your protected health information not be disclosed
to family members or friends who may be involved in your care or for
notification purposes as described in this Notice of Privacy
Practices. Your request must be in writing and state the specific
restriction requested and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you
may request. If your physician believes it is in your best interest
to permit use and disclosure of your protected health information,
your protected health information will not be restricted. If your
physician does agree to the requested restriction, we may not use or
disclose your protected health information in violation of that
restriction unless it is needed to provide emergency treatment. With
this in mind, please discuss any restriction you wish to request
with your physician. You may request a restriction by presenting
your request, in writing to a staff member. A simple sentence, “do
not use my PHI (protected health information) for education of
Chiropractic Students.” Or “Do not send any communication to my home
address.” Sign and date your request. Ask that the staff provide you
with a photocopy of your request initialed by them. This copy will
serve as your receipt.
You have the right to request to receive confidential communication
from us by alternative means or at an alternative location. We will
accommodate reasonable requests. We may also condition this
accommodation by asking you for information as to how payment will
be handled or specification of an alternative address or other
method of contact. We will not request an explanation from you as to
the basis for the request. Please make this request in writing to
our Privacy Contact.
You may have the right to have your physician amend your protected
health information. This means you may request an amendment of
protected health information about you in a designated record set
for as long as we maintain this information. In certain cases, we
may deny your request for an amendment. If we deny your request for
amendment, you have the right to file a statement of disagreement
with us and we may prepare a rebuttal to your statement and will
provide you with a copy of any such rebuttal. Please contact our
staff members to determine if you have questions about amending your
medical record.
You have the right to receive an accounting of certain disclosures
we have made, if any, of your protected health information. This
right applies to disclosures for purposes other than treatment,
payment or healthcare operations as described in this Notice of
Privacy Practices. It excludes disclosures we may have made to you,
for a facility directory, to family members or friends involved in
your case, pursuant to a duly executed authorization or for
notification purposes. You have the right to receive specific
information regarding theses disclosures that occurred after April
14, 2003. You may request a short timeframe. The right to receive
this information is subject to certain exceptions, restrictions and
limitations.
You have the right to obtain a paper copy of this notice from us,
upon request, even if you have agreed to accept this notice
electronically.
COMPLAINTS
You may complain to us or to the Secretary of Health and Human
Services if you believe your privacy rights have been violated by
us. You may file a complaint with us by notifying our staff members
of your complaint. We will not retaliate against you for filing a
complaint.
You may contact any staff member, including your physician at (231)
830-1111 for further information about the complaint process.
This notice was published and becomes effective on April 14, 2003. |
