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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 our Privacy Officer or any staff
member in our office.
Our
Privacy Officer is Kristin Olson.
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 operations of this
clinic. It also describes our policies concerning
the use and disclosure of this information for other
purposes that are permitted or required by law. It
describes your rights to access and control your
protected health information. “Protected Health
Information” (PHI) is information about you, including
demographic information that may identify you, that
relates to your past, present, or future physical or
mental health condition and related health care
services.
We are
required by federal law to abide by the terms of the
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 and
requesting that a revised copy be sent to you in the
mail or asking for one at the time of your next
appointment.
1.
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 doctor, 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 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 provide (e.g., a specialist of laboratory)
who, at the request of your doctor, becomes involved in
your care by providing assistance with your health care
diagnosis or treatment.
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 services
provided to you for medical necessity, and undertaking
utilization review activities. For example, obtaining
approval for chiropractic spinal adjustments 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 this office. These activities may include, but are
not limited to, quality assessment activities, employee
review activities and training of chiropractic students.
For
example, we may disclose your protected health
information to chiropractic interns or precepts that see
patients at our office. 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 doctor.
Communications between you and the doctor or his
assistants may be recorded to assist us in accurately
capturing your responses. We may also call you by name
in the reception area when your doctor 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 internal marketing activities. For example,
your name and address may be used to send you a
newsletter about our practice and the services we
offer. You may contact our Privacy Officer 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
use your demographic information to send you a thank you
card for a referral.
You may
revoke any of these authorizations, at any time, in
writing, except to the extent that your doctor or the
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 doctor 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 or general condition.
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 disclosure.
Public
Health:
We may disclose your protected health information for
public health activities and purposes to a public health
authority that is permitted by law to collect or
retrieve the information. The disclosure will be made
for the purpose of controlling disease, injury or
disability. We may also disclose your protected health
information, if directed by the public health authority,
to a foreign government agency that is collaborating
with the public health authority.
Communicable Diseases:
We may disclose your protected health information, if
authorized by law, to a person who may have been exposed
to a communicable disease or may otherwise be at risk of
contacting or spreading the disease or condition.
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
Abuse
or Neglect:
We may disclose your protected health information to a
public health authority that is authorized by law to
receive reports of child abuse or neglect. In addition,
we may disclose your protected health information if we
believe that you have been a victim of abuse, neglect or
domestic violence to the governmental entity or agency
authorized to receive such information. In this case,
the disclosure will be made consistent with the
requirements of applicable federal and state 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.
Law Enforcement:
We may also disclose protected health information, so
long as applicable legal requirements are met, for law
enforcement purposes. These law enforcement purposes
include (1) legal process and otherwise required by law,
(2) limited information requests for identification and
location purposes, (3) pertaining to victims of a crime,
(4) suspicion that death has occurred as a result of
criminal conduct, (5) in the event that a crime occurs
on the premises of the practice, and (6) medical
emergency (not on the Practice’s premises) and it is
likely that a crime has occurred.
Worker’s Compensation:
We may disclose your protected health information, as
authorized, to comply with workers’ compensation laws
and other similar legally established programs.
Required Uses and Disclosures:
Under the law, we must 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.
2. 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 doctor 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
complied 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 Privacy Officer, 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 healthcare
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 the 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
provider is not required to agree to a restriction that
you may request. If the doctor 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 doctor 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 doctor.
You may
request a restriction by presenting your request in
writing to the staff member identified as “Privacy
Officer” at the top of this form. The Privacy Officer
will provide you with the “Restriction of Consent to Use
and Disclosure of Protected Health Information” form.
Complete this form, sign it, and 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
communications 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, “Request for Confidential
Communications of Protected Health Information” is
available from the Privacy Officer.
You may
have the right to have your doctor 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 Privacy Officer 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 care, pursuant to a duly executed
authorization or for notification purposes. You have
the right to receive specific information regarding
these disclosures that occurred after April 14, 2003.
You may request a shorter timeframe. The right to
receive this information is subject to certain
exceptions, restrictions and limits.
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.
3.
Complaints
You may
complain to us, or 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 Privacy Officer of your complaint. We
will not retaliate against you for filing a complaint.
Our
Privacy Officer is Kristin Olson. You may contact our
Privacy Officer, or any staff member, including your
physician at the following phone number: 512-478-1613
for further information about the complaint process.
This
notice was published and becomes effective on April 14,
2003. |
