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NOTICE OF
PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
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.
Uses and Disclosures - Here are some examples of how we might have to
use or disclose your health care information:
1) Your chiropractor or a staff member may have to disclose your health
information including all of your clinical records to another health care
provider or a hospital if it is necessary to refer you to them for
diagnosis, assessment, or treatment of your health condition.
2) Our insurance and billing staff may have to disclose your examination and
treatment records and your billing records to another party, such as an
insurance carrier, an HMO, a PPO, or your employer, if they are potentially
responsible for the payment of your services.
3) Your chiropractor and members of the staff may need to use your health
information, examination and treatment records and your billing records for
quality control purposes or for other administrative purposes to efficiently
and effectively run our practice.
4) Your chiropractor and members of the practice staff may need to use your
name, address, phone number, and your clinical records to contact you to
provide appointment reminders, information about treatment alternatives, or
other health related information that may be of interest to you. 164.520
(b)(1)(iii)(A). If you are not at home to receive an appointment reminder, a
message will be left on your answering machine.
You have the right to refuse to give us authorization to contact you to
provide appointment reminders, information about treatment alternatives, or
other health related information. If you do not give us authorization, it
will not affect the treatment we provide to you or the methods we use to
obtain reimbursement for your care.
You may inspect or copy the information that we use to contact you to
provide appointment reminders, information about treatment alternatives, or
other health related information at any time.
Our Privacy Pledge - We have and always will respect your privacy.
Other than the uses and disclosures we described above, will not sell or
provide any of your health information to any outside marketing
organization.
Permitted uses and disclosures without your consent or authorization
- 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:
1) We are permitted to use or disclose your health information if we are
providing health care services to you based on the orders of another health
care provider.
2) We are permitted to use or disclose your health information if we provide
health care services to you as an inmate.
3) We are permitted to use or disclose your health information if we provide
health care services to you in an emergency.
4) We are permitted to use or disclose your health information if we are
required by law to treat you and we are unable to obtain your consent after
attempting to do so.
5) We are permitted to use or disclose your health information if there
substantial barriers to communicating with you, but in our professional
judgment we believe that you intend for us to provide care.
Other than the circumstances described in the preceding five examples, any
other use or disclosure of your health information will only be made with
your written authorization.
Your right to revoke your authorization - You may revoke your
authorization to us at any time; however, your revocation must be in
writing. There are two circumstances under which we will not be able to
honor your revocation request:
1) If we have already released your health information before we receive
your request to revoke your authorization. 164.508(b)(5)(i)
2) If you were required to give your authorization as a condition of
obtaining insurance, the insurance company may have a right to your health
information if they decide to contest any of your claims. If you wish to
revoke your authorization please write to us at: David Gerhart,, D.C., 303 S
32nd Street, Camp Hill , PA 17011.
Your right to limit uses or disclosures - If there are health care
providers, hospitals, employers, insurers or other individuals or
organizations to whom you do not want us to disclose your health
information, please let us know, in writing, what individuals or
organizations to whom you do not want us to disclose your health care
information. We are not required to agree to your restrictions. However, if
we agree with your restrictions, the restriction is binding on us. If we do
not agree to your restrictions, you may drop your request or you are free to
seek care from another health care provider.
Your right to receive confidential communication regarding your health
information - We normally provide information about your health to you
in person at the time you receive chiropractic services from us. We may also
mail you information regarding your health or about the status of your
account. We will do our best to accommodate any reasonable request if you
would like to receive information about your health or the services that we
provide at a place other than your home or, if you would like the
information in a different form. To help us respond to your needs, please
make any request in writing.
Your right to inspect and copy your health information - You have the
right inspect and/or copy your health information for seven years from the
date that the record was created or as long as the information remains in
our files. We require your request to inspect and/or copy your health
information to be in writing.
Your right to amend your health information - You have the right to
request that we amend your health information for seven years from the date
that the record was created or as long as the information remains in our
files. We require your request to amend your records to be in writing and
for you to give us a reason to support the change you are requesting us to
make.
Your right to receive an accounting of the disclosures we have made of
your records - You have the right to request that we give you an
accounting of the disclosures we have made of your health information for
the last six years before the date of your request. The accounting will
include all disclosures except:
• those disclosures required for your treatment, to obtain payment for your
services, or to run our practice.
• those disclosures made to you.
• those disclosures necessary to maintain a directory of the individuals in
our facility or to individuals involved with your care.
• those disclosures for national security or intelligence purposes.
• those disclosures made to correctional officers or law enforcement
officers.
• those disclosures those disclosures that were made prior to the effective
date of the HIPAA privacy law.
We will provide the first accounting within any 12-month period without
charge. There is a fee for any additional requests during the next 12
months. When you make your request we will tell you the amount of the fee
and you will have the opportunity to withdraw or modify your request.
Your right to obtain a paper copy of this notice - If you have agreed
to receive privacy notices by e-mail, you may request a paper copy of this
notice at any time.
Our duties - We are required by law to maintain the privacy of your
health information. We are also required to provide you with this notice of
your legal duties and our privacy practices with respect to your health
information.
We must abide by the terms of this notice while it is in effect. However, we
reserve the right to change the terms of our privacy notices. If we make a
change to the terms of our privacy agreement we will notify you in writing
when you come in for treatment or by mail. If we make a change in our
privacy terms the change will apply for all of your health information in
our files.
Re-disclosure - Information that we use or disclose may be subject to
re-disclosure by the person to whom we provide the information and may no
longer be protected by the federal privacy rules.
Your right to complain - You may complain to us or the the Secretary
for Health and Human Services if you feel that we have violated your privacy
rights. We respect your right to file a complaint and will not take any
action against you if you file a complaint. While you may make an oral
complaint at any time, written comments should be addressed to: David
Gerhart,, D.C., 303 S 32nd
Street, Camp Hill , PA 17011.
To contact us - If you would like further information about our
privacy policies and practices please contact: David Gerhart,
(717)761-2273
This notice is effective as of April 16, 2002. This notice will expire seven
years after the date upon which the record was created.
Copyright © 2002 Pennsylvania Chiropractic Association
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