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Notice
of Privacy Practices (HIPAA)
THIS
NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION. PLEASE REVIEW THIS NOTICE
CAREFULLY.
Adolph
Family Chiropractic (“The Practice”), in accordance with the federal
Privacy Rule, 45 CFR parts 160 and 164 (the “Privacy Rule”) and
applicable state law, is committed to
maintaining the privacy of your protected health information
(“PHI”). PHI includes
information about your health condition and the care and treatment
you receive from the Practice and is often referred to as your
health care or medical record.
This Notice explains how your PHI may be used and disclosed
to third parties. This
Notice also details your rights regarding your
PHI.
How the
Practice May Use and Disclose Your Protected Health
Information
The
Practice, in accordance with this Notice and without asking for your
express consent or authorization, may use and disclose your PHI for
the purposes of:
1) Treatment – To
provide you with the health care you require, the Practice may use
and disclose your PHI to those health care professionals, whether on
the Practice’s staff or not, so that it may provide, coordinate,
plan and manage your health care. For example, a chiropractor
treating you for lower back pain may need to know and obtain the
results of your latest physician examination or last treatment
plan.
2) Payment
– To get
paid for services provided to you, the Practice may provide your
PHI, directly or through a billing service, to a third party who may
be responsible for your care, including insurance companies and
health plans. If
necessary, the Practice may use your PHI in other collection efforts
with respect to all persons who may be liable to the Practice for
bills related to your care.
For example, the Practice may need to provide the Medicare
program with information about health care services that you
received from the Practice so that the Practice can be
reimbursed. The
Practice may also need to tell your insurance plan about treatment
you are going to receive so that it can determine whether or not it
will cover the treatment expense.
3) Health
Care Operations – To
operate in accordance with applicable law and insurance
requirements, and to provide quality and efficient care, the
Practice may need to compile, use and disclose your PHI. For example, the Practice
may use your PHI to evaluate the performance of the Practice’s
personnel in providing care to you.
Other
Examples of How the Practice May Use Your Protected Health
Information
1) Advice of
Appointment and Services
– The Practice may, from
time to time, contact you to provide appointment reminders or
information about treatment alternatives or other health-related
benefits and services that may be of interest to you. The following appointment
reminders may be used by the Practice: a) a postcard mailed to you
at the address provided by you; and b) telephoning your home and
leaving a message on your answering machine or with the individual
answering the phone.
2) Directory/Sign-In
Log
– The Practice maintains a
sign-in log at its reception desk for individuals seeking care and
treatment in the office.
The sign-in log is located in a position where staff can
readily see who is seeking care in the office, as well as the
individual’s location within the Practice’s office suite. This information may be seen
by, and is accessible to, others who are seeking care or services in
the Practice’s offices.
3) Open
Treatment Setting – The
Practice provides chiropractic adjusting, therapy, and rehab
services in an open setting, wherein others may observe you
receiving these services.
During treatment, your treatment record will be placed in a
transparent bin on the treatment room door where others may be able
to view its contents.
4) Family/Friends
– The Practice may disclose
to a family member, other relative, a close personal friend, or any
other person identified by you, your PHI directly relevant to such
person’s involvement with your care or the payment for your
care. The Practice may
also use or disclose your PHI to notify or assist in the
notification (including identifying or locating) a family member, a
personal representative, or another person responsible for your
care, of your location, general condition or death. However, in both cases, the
following conditions will apply:
- If you are present at or prior to the use or
disclosure of your PHI, the Practice may use or disclose your PHI
if you agree, or if the Practice can reasonably infer from the
circumstances, based on the exercise of its professional judgment
that you do not object to the use or disclosure.
- If you
are not present, the Practice will, in the exercise of
professional judgment, determine whether the use or disclosure is
in your best interests and, if so, disclose only the PHI that is
directly relevant to the person’s involvement with your
care.
5) Testimonials/Recognition – The
practice may openly post patient’s names or written statements from
patients to express appreciation to patients for their referrals and
testimonials.
Testimonials may also be used for marketing
purposes.
Other
Use and Disclosure Which May Be Permitted or Required by
Law
The
Practice may also use and disclose your PHI without your consent or
authorization in the following instances:
5) De-identified
Information – The
Practice may use and disclose health information that may be related
to your care but does not identify you and cannot be used to
identify you.
6) Business
Associate – The
Practice may use and disclose PHI to one or more of its business
associates if the Practice obtains satisfactory written assurance,
in accordance with applicable law, that the business associate will
appropriately safeguard your PHI. A business associate is an
entity that assists the Practice in undertaking some essential
function, such as a billing company that assists the office in
submitting claims for payment to insurance
companies.
7) Personal
Representative – The
Practice may use and disclose PHI to a person who, under applicable
law, has the authority to represent you in making decisions related
to your health care.
8) Emergency
Situations – The
Practice may use and disclose PHI for the purpose of obtaining or
rendering emergency treatment to you provided that the Practice
attempts to obtain your Consent as soon as possible: The Practice may also use
and disclose PHI to a public or private entity authorized by law or
by its charter to assist in disaster relief efforts, for the purpose
of coordinating your care with such entities in an emergency
situation.
9) Public
Health Activities – The
Practice may use and disclose PHI when required by law to provide
information to a public health authority to prevent or control
disease.
10)
Abuse,
Neglect or Domestic Violence – The
Practice may use and disclose PHI when authorized by law to provide
information if it believes that the disclosure is necessary to
prevent serious harm.
11)
Health
Oversight Activities – The
Practice may use and disclose PHI when required by law to provide
information in criminal investigations, disciplinary actions, or
other activities relating to the community’s health care system.
12)
Judicial
and Administrative Proceeding – The
Practice may use and disclose PHI in response to a court order or a
lawfully issued subpoena.
13)
Law
Enforcement Purposes – The
Practice may use and disclose PHI, when authorized, to a law
enforcement official.
For example, your PHI may be the subject of a grand jury
subpoena, or if the Practice believes that your death was the result
of criminal conduct.
14)
Coroner or
Medical Examiner – The
Practice may use and disclose PHI to a coroner or medical examiner
for the purpose of identifying you or determining your cause of
death.
15)
Organ, Eye
or Tissue Donation – The
Practice may use and disclose PHI if you are an organ donor to the
entity to whom you have agreed to donate your
organs.
16)
Research – The
Practice may use and disclose PHI subject to applicable legal
requirements if the Practice is involved in research
activities.
17)
Avert a
Threat to Health or Safety – The
Practice may use and disclose PHI if it believes that such
disclosure is necessary to prevent or lessen a serious and imminent
threat to the health or safety of a person or the public and the
disclosure is to an individual who is reasonably able to prevent or
lessen the threat.
18)
Specialized
Government Functions – The
Practice may use and disclose PHI when authorized by law with regard
to certain military and veteran activity.
19)
Workers’
Compensation – The
Practice may use and disclose PHI if you are involved in a Workers’
Compensation claim to an individual or entity that is part of the
Workers’ Compensation system.
20)
National
Security and Intelligence Activities – The
Practice may use and disclose PHI to authorized governmental
officials with necessary intelligence information for national
security activities.
21)
Military
and Veterans – The
Practice may use and disclose PHI if you are a member of the armed
forces, as required by the military command
authorities.
Authorization
Uses
and/or disclosures, other than those described above, will be made
only with your written Authorization.
Your
Rights
You have
the right to:
1) Revoke any Authorization or consent you
have given to the Practice, at any time. To request a revocation, you
must submit a written request to the Practice’s Privacy
Officer.
2) Request special restrictions on certain
uses and disclosures of your PHI as authorized by law. In general, this relates to
your right to request special restrictions concerning disclosures of
your PHI regarding uses for treatment, payment and operational
purposes under Privacy Rule, Section 164.522(a) and restrictions
related to disclosures to your family and other individuals involved
in your care under Privacy Rule, Section 164.510(b). Except in certain instances,
the Practice may not be obligated to agree to any requested
restrictions. To
request restrictions, you must submit a written request to the
Practice’s Privacy Officer.
In your written request, you must inform the Practice of what
information you want to limit, whether you want to limit the
Practice’s use or disclosure, or both, and to whom you want the
limits to apply. If the
Practice agrees to your request, the Practice will comply with your
request unless the information is needed in order to provide you
with emergency treatment.
3) Receive
confidential communications or PHI by alternative means or at
alternative locations as provided by Privacy Rule Section
164.522(b). For
instance, you may request all written communications to you marked
“Confidential Protected Health Information.” You must make your request
in writing to the Practice’s Privacy Officer. The Practice will
accommodate all reasonable requests.
4) Inspect
and copy your PHI as provided by federal law (including Privacy
Rule, Section 164.524) and state law. To inspect and copy your
PHI, you must submit a written request to the Practice’s Privacy
Officer. The Practice
can charge you a fee for the cost of copying, mailing or other
supplies associated with your request. In certain situations that
are defined by law, the Practice may deny your request, but you will
have the right to have the denial reviewed as set forth more fully
in the written denial notice.
5) Amend your
PHI as provided by federal law (including Privacy Rule, Section
164.526) and state law.
To request an amendment, you must submit a written request to
the Practice’s Privacy Officer. You must provide a reason
that supports your request.
The Practice may deny your request if it is not in writing,
if you do not provide a reason in support of your request, if the
information to be amended was not created by the Practice (unless
the individual or entity that created the information is no longer
available), if the information is not part of your PHI maintained by
the Practice, if the information is not part of the information you
would be permitted to inspect and copy, and/or if the information is
accurate and complete.
If you disagree with the Practice’s denial, you will have the
right to submit a written statement of disagreement.
6) Receive an
accounting of disclosures of your PHI as provided by federal law
(including Privacy Rule Section 164.528) and state law. To request an accounting,
you must submit a written request to the Practice’s Privacy
Officer. The request
must state a time period, which may not be longer than six (6) years
and may not include dates before April 14, 2003. The request should indicate
in what form you want the list (such as a paper or electronic
copy). The first list
you request within a twelve (12) month period will be free, but the
Practice may charge you for the cost of providing additional
lists. The Practice
will notify you of the costs involved and you can decide to withdraw
or modify your request before any costs are
incurred.
7) Receive a
paper copy of this Privacy Notice from the Practice (as provided by
Privacy Rule Section 164.520(b)(1)(iv)(F)) upon request to the
Practice’s Privacy Officer.
8) Complain
to the Practice or to the Secretary of HHS (as provided by Privacy
Rule Section 164.520(b)(1)(vi)) if you believe your privacy rights
have been violated. To
file a complaint with the Practice, you must contact the Practice’s
Privacy Officer. All
complaints must be in writing.
To obtain
more information about your privacy rights or if you have questions
you want answered about your privacy rights (as provided by Privacy
Rule Section 164.520(b)(2)(vii)), you may contact the Practice’s
Privacy Officer as follows:
M.
David
Taylor,
C.A., Adolph
Family Chiropractic, 8817
Belair Road, Suite 101,
Baltimore,
MD
21236,
410-256-9650
Practice’s
Requirements
The
Practice:
1) Is
required by federal law to maintain the privacy of your PHI and to
provide you with this Privacy Notice detailing the Practice’s legal
duties and privacy practices with respect to your
PHI.
2) Under the
Privacy Rule, may be required by State law to grant greater access
or maintain greater restrictions on the use or release of your PHI
than that which is provided for under federal law.
3) Is required to abide by the
terms of this Privacy Notice.
4) Reserves
the right to change the terms of this Privacy Notice and to make the
new Privacy Notice provisions effective for your entire PHI that it
maintains.
5) Will
distribute any revised Privacy Notice to you prior to
implementation.
6) Will not
retaliate against you for filing a complaint.
This
Notice is in effect as of 04/15/03.
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