Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below.
For example, with your written, signed authorization, we may make communication with you to promote products or services that may not be for the specific purpose providing treatment advice.
You may revoke any of these authorizations at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
In the following instance where we may use and disclose your protected health information, you have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:
• Required by Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
• Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
• Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
• Research: We may disclose your protected health information to researchers when an institutional review board has approved their research and that review board has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
• Required Uses and Disclosures: Under the law, we much make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
• You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physician and the practice uses for making decisions about you.
Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our staff members if you have questions about access to your medical record.
• You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply.
• Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by presenting your request, in writing to a staff member. A simple sentence, “do not use my PHI (protected health information) for education of Chiropractic Students.” Or “Do not send any communication to my home address.” Sign and date your request. Ask that the staff provide you with a photocopy of your request initialed by them. This copy will serve as your receipt.
• You have the right to request to receive confidential communication from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.
• You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our staff members to determine if you have questions about amending your medical record.
• You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your case, pursuant to a duly executed authorization or for notification purposes.
• You have the right to receive specific information regarding theses disclosures that occurred after April 14, 2003. You may request a short timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.
• You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our staff members of your complaint. We will not retaliate against you for filing a complaint. You may contact any staff member at 517.347.2222 for further information about the complaint process. This notice was published and becomes effective on April 15, 2003.
• Name Boards: This office may use name boards to acknowledge patients for referral and birthdays in open areas where others may view your name only. No other Protected Health Information would be used. You may also receive a nominal gift from this office.
• Open Treatment Rooms: You will have the opportunity to talk to your doctor and staff members in private. However, this practice provides treatment in an open area. This means that statements made by you or practice employees during treatment may be overheard by others. If you have comments you wish to make privately when you are brought to the treatment area or during treatment, please inform the doctor or staff and we will accommodate your request.
• Newsletters: Periodically, you will receive newsletters from this practice that highlight practice activities and information on products and services that will benefit your health
Explanation: The Privacy Rule describes a number of areas where this Practice may use and disclose Protected Health Information (PHI) without the patient’s express authorization. For example, to disclose a patient’s PHI for treatment, payment and health care operations of this Practice. Privacy Rules describe a number of situations where the Practice must disclose a patient’s Protected Health Information (PHI) pursuant to government orders, investigations and judicial process or to avert a serious threat to health or safety.
Privacy Rules require this Practice to obtain from the patient written approval in the form of an executed authorization to use and disclose the patient’s PHI for any other purposes. However, the Practice may never make the patient’s agreement to execute such an authorization a condition of care.
The most common use of an authorization by this Practice might be to provide the patient’s PHI to a person or entity that sells items or services, especially health care items or services, which the patient might be interested in.
This form is not needed if we intend to advise the patient of services or products that we can provide to aid in the patient’s care. It is only needed if we intend to provide the patient’s PHI to another business, so that they may, themselves, market the product or service.
The Practice’s form authorization should be used if this Practice intends to provide a patient’s PHI to some other person or entity for marketing purposes or any other purpose not permitted by the Privacy Rule or state law without such an authorization.
So that this office can treat you, receive payment for that treatment and run our health care operation, we may use your protected health information without your authorization to send to third party payers, administrators, etc.
• May be made with your written authorization
• With your signed authorization we may make communications with you to promote products and services that may not be for a specific purpose of providing treatment advice. You have the right to revoke this authorization. Other permitted and required uses and disclosures that may be made without your authorization or opportunity to object – we may disclose to a member of your family, a relative, a close friend or other person you identify, your protected health information that directly relates to that person’s involvement in your health care. We may also disclose your protected health information to an authorized public or private entity as required by law.
We may use or disclose your protected health information in the following situations:
• Required by law
• Health Oversight
• Legal Proceedings
• You may inspect or obtain a copy of your protected health information for as long as we maintain that information unless protected by federal law.
• You may ask us not to use or disclose any part of your protected health information for the purpose of treatment, payment or health care operation. Also, you may request that any part of your protected health information not be disclosed to your family members or friends who may be involved in your care. Your request must be in writing and state specific restrictions requested and to whom it applies.
• You may request that you receive these communications from us at an alternative location or by alternative means than is normally provided to other patients.
• You may request an amendment to your protected health information for as long as we maintain your protected health information. In certain cases we may deny your request for an amendment.
• You have the right to receive an accounting if we receive a request for disclosure of information for purposes other than treatment, payment and health care operations.
• You have the right to receive a complete copy of our privacy practices by paper or electronically.
• If you believe your privacy rights have been violated, you may complain to us or to the Secretary of Health & Human Services.
• This notice was published and becomes effective April 15, 2003.