THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
Our practices are dedicated, and we are required by applicable federal and state laws, to maintain
the privacy of your health information. These laws also require us to provide you with this
Notice of our privacy practices, and to inform you of your rights, and our obligations, concerning
your health information. We are required to follow the privacy practices described below while
this Notice is in effect. This Notice is effective as of 06/01/13, and will remain in effect until we
CHANGES TO NOTICE:
We reserve the right to change this Notice and the privacy practices described below at any time
in accordance with applicable law. Prior to making significant changes to our privacy practices,
we will alter this Notice to reflect the changes, and make the revised Notice available to you on
request. Any changes we make to our privacy practices and/or this Notice may be applicable to
health information created or received by us prior to the date of the changes.
You may request a copy of our Notice at any time. For more information about our privacy
practices, or for additional copies of this Notice, please contact us using the information listed at
the end of this Notice.
PERMITTED USES AND DISCLOSURES OF HEALTH INFORMATION:
A. CONSENT: You should be aware that during the course of our relationship with you, we will
likely use and disclose health information about you for treatment, payment, and healthcare
operations. Examples of these activities are as follows:
Treatment: We may use or disclose your health information to another healthcare
provider or medical doctor providing treatment to you, so that we may coordinate, plan,
and manage your health care.
Payment: We may use and disclose your health information to obtain payment for
services we provide to you. We may provide your health information, directly or through
a billing service, to a third party who may be responsible for your care, including health
insurance companies and health plans.
Healthcare Operations: We may use and disclose your health information in connection
with our healthcare operations. Healthcare operations include quality assessment and
improvement activities, reviewing the competence or qualifications of healthcare
professionals, evaluating practitioner and provider performance, and other business
Our chiropractic practice will seek to obtain Consent from you permitting us to use or disclose
your health information for these activities. You should be aware that our chiropractic practice
does not require obtaining, or confirming the existence of a Consent, prior to:
a) Emergency treatment;
b) Treatment, when such treatment is required by law; or
c) Treatment of patients when communication barriers prevent obtaining Consent.
You should also be aware that you have the right to revoke that Consent at any time by providing
the practice with written notice.
B. AUTHORIZATIONS: You may specifically authorize us to use your health information for
any purpose or to disclose your health information to anyone, by submitting such an authorization
in writing. Upon receiving an authorization from you in writing we may use or disclose your
health information in accordance with that authorization. You may revoke an authorization at
any time by notifying us in writing. Your revocation will not affect any use or disclosures
permitted by your authorization while it was in effect. Unless you give us a written authorization,
we cannot use or disclose your health information for any reason except those permitted by this
C. DISCLOSURES TO FAMILY AND PERSONAL REPRESENTATIVES: We must disclose
your health information to you, as described in the Patient Rights section of this Notice. Such
disclosures will be made to any of your personal representatives appropriately authorized to have
access and control of your health information. We may disclose your health information to a
family member, friend or other person to the extent necessary to help with your healthcare or with
payment for your healthcare only if authorized to do so. In the event of your incapacity or in
emergency circumstances, we will disclose health information based on a determination using our
professional judgment disclosing only health information that is directly relevant to the person’s
involvement in your healthcare.
D. MARKETING: We will not use your health information for marketing communications
without your written authorization.
E. USES OR DISCLOSURES REQUIRED BY LAW: We may use or disclose your health
information when we are required to do so by law, including for public health reasons (e.g.,
disease reporting). In some instances, and in accordance with applicable law, we may be required
to disclose your health information to appropriate authorities if we reasonably believe that you are
a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes.
F. PATIENT AND THIRD PARTY PROTECTION: Only as permitted by law, we may disclose
your health information to the extent necessary to avert a serious threat to your health or safety or
the health or safety of others.
G. LAW ENFORCEMENT/NATIONAL SECURITY: Under certain circumstances we may
disclose health information relating to members of the Armed Forces to military authorities.
Under certain circumstances we may also disclose health information relating to inmates or
patients to correctional institutions or law enforcement personnel having lawful custody of those
individuals. We may disclose health information in response to judicial proceedings and law
enforcement inquiries as permitted by law and to authorized federal officials health information
required for lawful intelligence, counterintelligence, and other national security activities.
H. APPOINTMENT REMINDERS: We may use or disclose your health information to
provide you with appointment reminders (such as voicemail messages or leaving a message with
the individual answering the phone, a postcard mailed to you at the address by you, or a letter).
A. ACCESS TO RECORDS: Upon submission of a written request to us, you have the right to
review or receive copies of your health information, with limited exceptions. You may obtain a
form to request access by using the contact information listed at the end of this Notice. You may
request that we provide copies in a format other than photocopies and we will use the format you
request if it is readily available. We will charge you a reasonable cost-based fee relating to the
production of such copies. If you request copies, we will charge you $___ for each page, plus
postage, if you want the copies mailed to you. If you request an alternative format, we will
charge a reasonable cost-based fee for providing your health information in that format. If you
prefer, we will prepare a summary or an explanation of your health information for a fee. Contact
us using the information listed at the end of this Notice if you are interested in receiving a
summary of your information instead of copies.
B. ACCOUNTING OF CERTAIN DISCLOSURES. Upon written request, you have the right to
receive a list of instances in which we or our business associates disclosed your health
information for purposes, other than treatment, payment, healthcare operations and other
activities authorized by you, for the last 6 years, but not before April 14, 2003. If you request this
accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee
for responding to these additional requests.
C. RESTRICTIONS AND ALTERNATIVE COMMUNICATIONS: You have the right to
request that we place additional restrictions on our use or disclosure of your health information
for treatment, payment and healthcare operations purposes. Depending on the circumstances of
your request we may, or may not agree to those restrictions. If we do agree to your requested
restrictions we must abide by those restrictions, except in emergency treatment scenarios. You
have the right to request that we communicate with you about your health information by
alternative means or to alternative locations (e.g., at your place of business rather than at your
home). Such requests must be made in writing, must specify the alternative means or location,
and must provide satisfactory explanation how payments will be handled under the alternative
means or location you request.
D. AMENDMENTS TO RECORDS: You have the right to request that we amend your health
information. Such requests must be made in writing, and must explain why the information
should be amended. We may deny your request under certain circumstances.
E. ELECTRONIC NOTICES. If you receive this Notice on our Web site or by electronic mail
(e-mail), you are entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please
contact us. If you are concerned that we may have violated your privacy rights, or you disagree
with a decision we made or any decisions we may make regarding the use, disclosure, or access
to your health information you may complain to us using the contact information listed below.
You also may submit a written complaint to the U.S. Department of Health and Human Services.
We will provide you with the address to file such a complaint upon request.
We support your right to the privacy of your health information. We will not retaliate in any way
if you choose to file a complaint with us or with the U.S. Department of Health and Human