Notice of Privacy Practices for Protected Health Information for CHIRO-CENTER
THIS FORM IS NOW REQUIRED BY THE UNITED STATES GOVERNMENT UNDER HIPPA REGULATIONS.
THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Please review it carefully.
Our Privacy Pledge: We here at CHIRO-CENTER have and always will respect your privacy. Other than the uses and disclosures we describe in this notice, We will not sell or provide any of your health information to any outside marketing organization.
Use and Disclosure of Your Protected Health Information:
- Treatment – To provide you with the health care you require we may need to disclose your health information to another health care provider or hospital if it is necessary to refer you to them for diagnosis, assessment, or treatment of your health condition.
- Payment – Our insurance and billing staff member may have to disclose your examination and treatment records and your billing records to another party, such as an insurance carrier or your employer, if they are potentially responsible for the payment of your services.
- Appointment Reminder – A member of our staff may need to contact you to provide appointment reminders. If you are not at home or work to receive an appointment reminder, a message will be left on your answering machine. If this is a problem please note your preferred method of contact in writing to our staff. We will accommodate all reasonable requests.
- Personal Representative – We may disclose some of your Personal Health Information to someone who, under applicable law, has the authority to represent you in making decisions related to your health care.
- Emergency Situations – We may use and disclose information for the purpose of obtaining or rendering emergency treatment to you. We may also disclose your health information to a coroner or medical examiner for the purpose of identifying you or determining your cause of death. Also for the purpose of organ donation if you are an organ donor.
- Law Enforcement Purposes – We may be required to disclose your personal health information to any Law Enforcement Agency if necessary for national security, public health safety, to report abuse or neglect, or in response to a court order.
- Workers’ Compensation– We may use and disclose your information if you are involved in a Workers’ Compensation claim, to an individual or entity that is part of the Workers’ Compensation system.
- Other – All other uses and disclosures by us will require us to obtain from you a written authorization.
Your Rights: You have the following rights concerning your Personal Health Information:
- To revoke any Authorization or consent you have given to us, at any time. To request a revocation, you must submit a written request to the Chiro-Center’s Office Manager.
- To request restricted access to all or part of you Personal Health Information. To do this you must submit a written request informing us of what information you want to limit and to whom you want the limits to apply. We will honor your request unless that information is needed to provide you with emergency treatment. Please submit all written requests to our Office Manager.
- To request a copy and inspect your Personal Health information. To request a copy, you must submit a written request to the Office Manager. We can charge you a fee for the cost of copying, mailing or other supplies associated with your request.
- You have the right to amend your Personal Health Information. To request an amendment, you must submit a written request to the Office Manager. You must provide a reason that supports your request. We have the right to deny your request.
- To receive an accounting of the disclosures by us of your Personal Health Information. We are required to keep a record for six years. To do this, please submit your request in writing to the Office Manager.
- To receive a written copy or updates of this notice, at your request.
- To complain to us or to the U.S. Department of Health & Human Services if you believe your privacy rights have been violated. To do this, please contact the Office Manager, and submit the complaint in writing.
Our Duties: We are required to maintain the privacy of your Personal Health Information and to provide you with this notice of our legal duties and our privacy practices with respect to your health information.
2323 Naperville Rd., #180
Naperville, IL 60563