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.
OUR COMMITMENT TO YOUR PRIVACY
Your health information is personal. We are committed to protecting your medical information. This Notice explains how we may use and disclose your health information and describes your rights regarding that information. We are required by law to maintain the privacy of your protected health information, provide you with this Notice of our legal duties and privacy practices, and follow the terms of this Notice currently in effect.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
Treatment: We may use your health information to provide, coordinate, or manage your chiropractic care and share information with other healthcare providers involved in your care.
Payment: We may use and disclose your health information to bill and collect payment for services provided to you.
Healthcare Operations: We may use and disclose your information to operate our practice, improve patient care, evaluate provider performance, and conduct administrative functions.
OTHER USES AND DISCLOSURES PERMITTED OR REQUIRED BY LAW
We may disclose your health information for public health and safety activities, reporting abuse or neglect, health oversight activities, judicial or administrative proceedings, law enforcement purposes, workers’ compensation claims, to avert serious threats to health or safety, or as otherwise required by law.
USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION
We will not use or disclose your health information for marketing purposes or the sale of your health information without your written authorization. You may revoke your authorization at any time in writing.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following rights:
Right to Inspect and Copy — You may request access to your medical records and obtain copies.
Right to Request Amendment — If you believe your health information is incorrect or incomplete, you may request that we correct it.
Right to Request Restrictions — You may request limits on how we use or disclose your information. We are not required to agree to all requests.
Right to Confidential Communications — You may request that we contact you in a specific way (for example, only by phone or mail).
Right to an Accounting of Disclosures — You may request a list of certain disclosures we have made of your health information.
Right to a Paper Copy of This Notice — You may request a paper copy at any time, even if you agreed to receive it electronically.
OUR RESPONSIBILITIES
We are required by law to maintain the privacy and security of your protected health information and notify you if a breach occurs that may have compromised your information.
We reserve the right to change the terms of this Notice and make the new Notice effective for all health information we maintain. Updated notices will be available upon request and posted in our office.
QUESTIONS OR COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.
Privacy Officer: ______________________________
Practice Address: _____________________________
Phone: _______________________________________
Email: _______________________________________
You may also file a complaint with:
U.S. Department of Health and Human Services, Office for Civil Rights
EFFECTIVE DATE
Effective Date: ______________________________