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Smith Chiropractic
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.
Smith Chiropractic is required, by law, to
maintain the privacy and confidentiality of your protected health information and to
provide our patients with notice of our legal duties and privacy practices with
respect to your protected health information.
Disclosure of Your Health Care Information
Treatment
We may disclose your health care information
to other healthcare professionals within our practice for the purpose of treatment,
payment or healthcare operations. (example)
“On occasion, it may be necessary to seek
consultation regarding your condition from other health care providers associated
with Smith Chiropractic.”
“It is our policy to provide a substitute
health care provider, authorized by Smith Chiropractic to provide assessment
and/or treatment to our patients, without advanced notice, in the event of your
primary health care provider’s absence due to vacation, sickness, or other
emergency situation.”
Payment
We may disclose your health information to
your insurance provider for the purpose of payment or health care operations.
(example)
“As a courtesy to our patients, we will
submit an itemized billing statement to your insurance carrier for the purpose of
payment to Smith Chiropractic for health care services rendered. If you pay for
your health care services personally, we will, as a courtesy, provide an itemized
billing to your insurance carrier for the purpose of reimbursement to you. The
billing statement contains medical information, including diagnosis, date of
injury or condition, and codes which describe the health care services received.
In addition we send patient billings to the home addresses of our patients.”
Workers’ Compensation
We may disclose your health information as
necessary to comply with State Workers’ Compensation Laws.
Emergencies
We may disclose your health information to
notify or assist in notifying a family member, or another person responsible for
your care about your medical condition or in the event of an emergency or of your
death.
Incidental Disclosures
There may be incidental disclosures of your
health information, primarily your name, as you participate in care at Smith
Chiropractic. (examples)
“When you come into the office for treatment
you will be asked to sign your name on a sign in sheet. We have a bulletin board in
the waiting room when the names of referring patients are posted. Your name may be
seen on the chart as it sits in the holder outside of treatment rooms or in the
check out basket at the front desk. There may be file or x-ray folders in or outside
treatment rooms that have your name on it and health information in it. There my be
other instances where your name may be mentioned in the confines of the office while
providing treatment, procuring payments or in the operation of Smith Chiropractic .
Public Health
As required by law, we may disclose your
health information to public health authorities for purposes related to: preventing
or controlling disease, injury or disability, reporting child abuse or neglect,
reporting domestic violence, reporting to the Food and Drug Administration problems
with products and reactions to medications, and reporting disease or infection
exposure.
Judicial and Administrative Proceedings.
We may disclose your health information in the
course of any administrative or judicial proceeding.
Law Enforcement.
We may disclose your health information to a
law enforcement official for purposes such as identifying or locating a suspect,
fugitive, material witness or missing person, complying with a court order or
subpoena, and other law enforcement purposes.
Deceased Persons.
We may disclose your health information to coroners or medical
examiners.
Organ Donation. We may disclose your health information to
organizations involved in procuring, banking, or transplanting organs and tissues.
Research.
We may disclose your health information to
researchers conducting research that has been approved by an Institutional Review
Board.
Public Safety.
It may be necessary to disclose your health
information to appropriate persons in order to prevent or lessen a serious and
imminent threat to the health or safety of a particular person or to the general
public.
Specialized Government Agencies.
We may disclose your health information for
military, national security, prisoner and government benefits purposes.
Marketing.
We may contact you for marketing purposes or
fundraising purposes, as described below: (example)
“As a courtesy to our patients, it is our
policy to call your home on the evening prior to your scheduled appointment to
remind you of your appointment time or to call after you have missed an
appointment. If you are not at home, we leave a reminder message on your answering
machine or with the person answering the phone. No personal health information
will be disclosed during this recording or message other than the date and time of
your scheduled appointment along with a request to call our office if you need to
cancel or reschedule your appointment.”
“It is our practice to participate in
charitable events to raise awareness, food donations, gifts, money, etc. During
these times, we may send you a letter, post card, invitation or call your home to
invite you to participate in the charitable activity. We will provide you with
information about the type of activity, the dates and times, and request your
participation in such an event. It is not our policy to disclose any personal
health information about your condition for the purpose of Smith Chiropractic
sponsored fund-raising events.”
“ We also send regular newsletters and
other health and promotional information to the addresses of our patients.”
Change of Ownership.
In the event that Smith Chiropractic is sold
or merged with another organization, your health information/record will become the
property of the new owner.
Your Health Information Rights
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You have the right
to request restrictions on certain uses and disclosures of your health
information. Please be advised, however, that Smith Chiropractic is not required
to agree to the restriction that you requested.
-
You have the right
to have your health information received or communicated through an alternative
method or sent to an alternative location other than the usual method of
communication or delivery, upon your request.
-
You have the right
to inspect and copy your health information.
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You have a right to
request that Smith Chiropractic amend your protected health information. Please be
advised, however, that Smith Chiropractic is not required to agree to amend your
protected health information. If your request to amend your health information has
been denied, you will be provided with an explanation of our denial reason(s)and
information about how you can disagree with the denial.
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You have a right to
receive an accounting of disclosures of your protected health information made by
Smith Chiropractic.
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You have a right to
a paper copy of this Notice of Privacy Practices at any time upon request.
Changes to this Notice of Privacy Practices
Smith Chiropractic reserves the right to amend
this Notice of Privacy Practices at any time in the future, and will make the new
provisions effective for all information that it maintains. Until such amendment is
made, Smith Chiropractic is required by law to comply with this Notice.
Smith Chiropractic is required by law to
maintain the privacy of your health information and to provide you with notice of
its legal duties and privacy practices with respect to your health information. If
you have questions about any part of this notice or if you want more information
about your privacy rights, please contact Stephen W. Smith, D.C. by calling this
office at (714) 527-3332. If Stephen W. Smith, D.C. is not available, you may make
an appointment for a personal conference in person or by telephone within 2 working
days.
Complaints
Complaints about your Privacy rights, or how
Smith Chiropractic has handled your health information should be directed to Stephen
W. Smith, D.C. by calling this office at (714) 527-3332. If Stephen W. Smith, D.C.
is not available, you may make an appointment for a personal conference in person or
by telephone within 2 working days.
If you are not satisfied with the manner in
which this office handles your complaint, you may submit a formal complaint to:
DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
This notice is effective as of March 03, 2003.
I have read the Privacy Notice and understand my rights
contained in the notice.
By way of my signature, I provide with my
authorization and consent to use and disclosed my protected health care information
for the purposes of treatment, payment and health care operations as described in
the Privacy Notice
________________________________________________
Patient’s Name (print)
________________________________________________
______________
Patient’s Signature
Date
________________________________________________
______________
Authorized Facility Signature
Date
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