Danville Chiroteam, Inc. (dba Family Chiropractic)
THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY THIS OFFICE, AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
Family Chiropractic (the “Practice”) is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about your health condition and history, as well as, the care and treatment you receive from the Practice and other health care providers. This Notice details how your PHI may be used and disclosed to third parties for purposes of your care, payment for your care, health care operations of the Practice, and for other purposes permitted or required by law. This notice also details your rights regarding your PHI.
This Practice may employ multiple Doctors of Chiropractic at any given time. However, for purposes of compliance with the Health Information Portability and Accountability Act (HIPAA) Privacy rules, all doctors are deemed to be a part of a single Organized Health Care Arrangement, which means: that they operate as an integrated unit; that they will share protected health information in order to carry out chiropractic care (including coverage for each other), payment for services rendered and health care operations; that this Notice is provided as a joint notice made by each doctor; and, that each of them will abide by the terms of this Notice.
This office maintains a sign-in log at the reception area that you are asked to sign before seeing the doctor. Your name may be seen by others who are in the reception area.
Also, we provide most ongoing care in an “open adjusting” format. It is NOT the environment used for taking patient histories, performing examinations or presenting reports of findings. These procedures are completed in a private, confidential setting. This means that statements made by you or office employees during treatment may be overheard by others. There are various interpretations under federal law with respect to what is known as “incidental disclosures” of health information. It is our view that the kinds of matters related in an “open adjusting” environment are incidental matters. If you have comments or information you wish to share privately when you are brought to the “open adjusting” area or during treatment, please inform the doctor or staff and we will accommodate your request. You will have the opportunity to talk to your doctor and staff members in private.
In the course of your care as a patient at Family Chiropractic, we may use or disclose personal and health related information about you in the following ways:
*Your personal health information, including of your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
*Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are or may be responsible for the payment of your services.
*Your name, address, phone number, and your health care records may be used to correspond with you during your care. This may include contacting you regarding: appointment reminders, recommendation notices, birthdays, holidays, referral thank-you cards, practice events, information about alternatives to your present care, or other health related information (i.e. newsletters, e-mails, etc.) that may be interest to you, as well as, other, similar correspondence.
Further, you have the right to inspect or obtain a copy of the information we will use for these purposes. If you are not at home to receive an appointment reminder call, a message may be left on your answering machine. You also have the right to refuse to provide authorization for this office to contact you regarding these matters. If you do not provide us with this authorization it will not affect the care provided to you or the reimbursement avenues associated with your care.
Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following circumstances:
*If we are providing health care services to you based on the orders of another health care provider.
*If we provide health care services to you in an emergency or if we are required by law to provide care and are unable to obtain your consent after attempting to do so.
*If we are ordered by the courts or another appropriate agency. Also, when required by law (i.e. case of abuse and neglect.) or for special government functions (i.e. military, veteran officers, foreign military) and to correctional institutions in the case of inmates.
*If you are involved in a Workers’ Compensation claim, we may be required to disclose your PHI to an individual or entity that is part of the Workers’ Compensation system.
*If we contract with a business associate to provide a service necessary for your treatment, payment for your treatment and health care operations (e.g. billing service or transcription service). We will obtain satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI.
Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or, if you would like the information in a different form, please advise us in writing as to your preferences.
You have the right to inspect and/or request a copy of your health information for seven years from the date that the record was created or as long as the information remain in our files. In addition you have the right to request an amendment to your health information. Requests to inspect, copy or amend your health related information must be made, in writing to the Practice’s Privacy Officer, Jon A. Bradbury, D.C. at 5101 S. US Hwy 41, Terre Haute, Indiana, 47802.
We are required by state and federal law to maintain the privacy of your patient file and the protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information, and to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all of your health
information in our files. Information that we use or disclose based on this privacy notice may be subject to redisclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.
If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to Jon A. Bradbury, D.C.
This notice is effective as of __01/16/2006_. This notice, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created, or as long as I remain under care, whichever is longer.
If I discontinue chiropractic care in this office, this notice will remain in effect until the time the practice is required by Indiana law to retain my records. My signature acknowledges that a copy of this notice has been presented and made available to me on the date indicated.
_______________________ _________________________ _______________
Name (Printed please) Signature Date
If you are a minor, or if you are being represented by another party
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Personal Rep. (Printed) Personal Rep. Signature Date
Description of the authority to act on behalf of the patient