NOTICE OF PRIVACY PRACTICES This Notice is effective September 23, 2013
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
WE ARE REQUIRED BY LAW TO PROTECT MEDICAL INFORMATION ABOUT YOU
We are required by law to protect the privacy of medical information about you and that identifies you.
This medical information may be information about health care we provide to you or payment for health
care provided to you. It may also be information about your past, present, or future medical condition.
We are also required by law to provide you with this Notice of Privacy Practices explaining our legal
duties and privacy practices with respect to medical information. We are required by law to notify you
following a breach of unsecured protected health information. We are legally required to follow the terms
of this Notice. In other words, we are only allowed to use and disclose medical information in the manner
that we have described in this Notice.
We may change the terms of this Notice in the future. We reserve the right to make changes and to
make the new Notice effective for all medical information that we maintain. If we make changes to the
Notice, we will:
• Post the new Notice in our waiting area.
• Have copies of the new Notice available upon request (you may always contact our Privacy
Officer at this Clinic’s main phone number to obtain a copy of the current Notice).
The rest of this Notice will:
• Discuss how we may use and disclose medical information about you.
• Explain your rights with respect to medical information about you.
• Describe how and where you may file a privacy-related complaint.
If, at any time, you have questions about information in this Notice or about our privacy policies,
procedures or practices, you can contact our Privacy Officer at this Clinic’s main phone number.
WE MAY USE AND DISCLOSE MEDICAL INFORMATION
ABOUT YOU IN SEVERAL CIRCUMSTANCES
We use and disclose medical information about patients every day. This section of our Notice explains in
some detail how we may use and disclose medical information about you in order to provide health care,
obtain payment for that health care, and operate our business efficiently. This section then briefly
mentions several other circumstances in which we may use or disclose medical information about you.
WE MAY USE AND DISCLOSE MEDICAL INFORMATION
ABOUT YOU IN SEVERAL CIRCUMSTANCES For more information about any of these uses or disclosures, or about any of our privacy policies,
procedures or practices, contact our Privacy Officer at this Clinic’s main phone number.
We may use and disclose medical information about you to provide health care treatment to you. In other
words, we may use and disclose medical information about you to provide, coordinate or manage your
health care and related services. This may include communicating with other health care providers
regarding your treatment and coordinating and managing your health care with others. We may also use
your information to contact you to provide appointment reminders or information about treatment
alternatives or other health-related benefits and services that may be of interest to you.
Example: Jane is a patient at the chiropractic clinic. The receptionist may use medical information about
Jane when setting up an appointment. The doctor will likely use medical information about Jane when
reviewing Jane’s condition and ordering an x-ray or MRI. The laboratory technician will likely use medical
information about Jane when processing or reviewing her scan or test results. If, after reviewing the
results of the scans/tests, the doctor concludes that Jane should be referred to a specialist, the doctor
may disclose medical information about Jane to the specialist to assist the specialist in providing
appropriate care to Jane.
We may use and disclose medical information about you to obtain payment for health care services that
you received. This means that, within the chiropractic clinic, we may use medical information about you
to arrange for payment (such as preparing bills and managing accounts). We also may disclose medical
information about you to others (such as insurers, collection agencies, and consumer reporting agencies).
In some instances, we may disclose medical information about you to an insurance plan before you
receive certain health care services because, for example, we may want to know whether the insurance
plan will pay for a particular service.
Example: Jane is a patient at the chiropractic clinic and she has private insurance. During an
appointment with a doctor, the doctor ordered an x-ray or MRI or blood test. The chiropractic clinic billing
clerk will use medical information about Jane when he prepares a bill for the services provided at the
appointment and the scan or blood test. Medical information about Jane will be disclosed to her
insurance company when the billing clerk sends in the bill.
Example: The doctor referred Jane to a specialist. The specialist recommended several complicated
and expensive tests. The specialist’s billing clerk may contact Jane’s insurance company before the
specialist runs the tests to determine whether the plan would pay for the test.
3. Healthcare Operations
We may use and disclose medical information about you in performing a variety of business activities that
we call “health care operations.” These “health care operations” activities allow us to, for example,
improve the quality of care we provide and reduce health care costs. For example, we may use or
disclose medical information about you in performing the following activities:
• Reviewing and evaluating the skills, qualifications, and performance of health care providers
taking care of you.
• Providing training programs for students, trainees, health care providers or non-health care
professionals to help them practice or improve their skills.
• Cooperating with outside organizations that evaluate, certify or license health care providers,
staff or facilities in a particular field or specialty.
• Reviewing and improving the quality, efficiency and cost of care that we provide to you and our
• Improving health care and lowering costs for groups of people who have similar health
problems and helping manage and coordinate the care for these groups of people.
• Cooperating with outside organizations that assess the quality of the care others and we
provide, including government agencies and private organizations.
• Planning for our organization’s future operations. • Resolving grievances within our organization.
• Reviewing our activities and using or disclosing medical information in the event that control of
our organization significantly changes.
• Working with others (such as lawyers, accountants and other providers) who assist us to
comply with this Notice and other applicable laws.
Example: Jane was diagnosed with a certain condition. The chiropractic clinic used Jane’s medical
information – as well as medical information from all of the other clinic patients diagnosed with the same
condition – to develop an educational program to help patients recognize the early symptoms of this
condition. (Note: The educational program would not identify any specific patients without their
Example: Jane complained that she did not receive appropriate health care. The chiropractic clinic
reviewed Jane’s record to evaluate the quality of the care provided to Jane. The chiropractic clinic also
discussed Jane’s care with an attorney.
4. Persons Involved in Your Care
We may disclose medical information about you to a relative, close personal friend or any other person
you identify if that person is involved in your care and the information is relevant to your care. We will
limit the disclosure to the information relevant to that person’s involvement in your healthcare or payment.
If the patient is a minor, we may disclose medical information about the minor to a parent, guardian or
other person responsible for the minor except in limited circumstances. For more information on the
privacy of minors’ information, contact our Privacy Officer at this Clinic’s main phone number.
We may also use or disclose medical information about you to a relative, another person involved in your
care or possibly a disaster relief organization (such as the Red Cross) if we need to notify someone about
your location or condition.
You may ask us at any time not to disclose medical information about you to persons involved in your
care. We will agree to your request and not disclose the information except in certain limited
circumstances (such as emergencies) or if the patient is a minor. If the patient is a minor, we may or may
not be able to agree to your request.
Example: Jane’s husband regularly comes to the chiropractic clinic with Jane for her appointments and
he helps her with her physical therapy. When the doctor is discussing a new therapy with Jane, Jane
invites her husband to come into the private room. The doctor discusses the new treatment with Jane
and Jane’s husband.
5. Required by Law
We will use and disclose medical information about you whenever we are required by law to do so. There
are many state and federal laws that require us to use and disclose medical information. For example,
state law requires us to report gunshot wounds and other injuries to the police and to report known or
suspected child abuse or neglect to the Department of Social Services. We will comply with those state
laws and with all other applicable laws.
6. National Priority Uses and Disclosures
When permitted by law, we may use or disclose medical information about you without your permission
for various activities that are recognized as “national priorities.” In other words, the government has
determined that under certain circumstances (described below), it is so important to disclose medical
information that it is acceptable to disclose medical information without the individual’s permission. We
will only disclose medical information about you in the following circumstances when we are permitted to
do so by law. Below are brief descriptions of the “national priority” activities recognized by law. For more
information on these types of disclosures, contact our Privacy Officer at this Clinic’s main phone number.
• Threat to health or safety: We may use or disclose medical information about you if we
believe it is necessary to prevent or lessen a serious threat to health or safety.
• Public health activities: We may use or disclose medical information about you for public
health activities. Public health activities require the use of medical information for various activities, including, but not limited to, activities related to investigating diseases, reporting child
abuse and neglect, monitoring drugs or devices regulated by the Food and Drug
Administration, and monitoring work-related illnesses or injuries. For example, if you have
been exposed to a communicable disease (such as a sexually transmitted disease), we may
report it to the State and take other actions to prevent the spread of the disease.
• Abuse, neglect or domestic violence: We may disclose medical information about you to a
government authority (such as the Department of Social Services) if you are an adult and we
reasonably believe that you may be a victim of abuse, neglect or domestic violence.
• Health oversight activities: We may disclose medical information about you to a health
oversight agency – which is basically an agency responsible for overseeing the health care
system or certain government programs. For example, a government agency may request
information from us while they are investigating possible insurance fraud.
• Court proceedings: We may disclose medical information about you to a court or an officer
of the court (such as an attorney). For example, we would disclose medical information about
you to a court if a judge orders us to do so.
• Law enforcement: We may disclose medical information about you to a law enforcement
official for specific law enforcement purposes. For example, we may disclose limited medical
information about you to a police officer if the officer needs the information to help find or
identify a missing person.
• Coroners and others: We may disclose medical information about you to a coroner, medical
examiner, or funeral director or to organizations that help with organ, eye and tissue
• Workers’ compensation: We may disclose medical information about you in order to comply
with workers’ compensation laws.
• Research organizations: We may use or disclose medical information about you to research
organizations if the organization has satisfied certain conditions about protecting the privacy of
• Certain government functions: We may use or disclose medical information about you for
certain government functions, including but not limited to military and veterans’ activities and
national security and intelligence activities. We may also use or disclose medical information
about you to a correctional institution in some circumstances.
Other than the uses and disclosures described above (#1-6), we will not use or disclose medical
information about you without the “authorization” – or signed permission – of you or your personal
representative. In some instances, we may wish to use or disclose medical information about you and we
may contact you to ask you to sign an authorization form. In other instances, you may contact us to ask
us to disclose medical information and we will ask you to sign an authorization form. For example, the
chiropractic clinic will obtain your written consent if it wishes to use your protected health information to
contact you with educational and promotional items in the future via email, U.S. Mail, telephone, fax
and/or prerecorded messages.
By federal law, we must obtain authorization by you (1) to use or disclose most psychotherapy notes, (2)
for most marketing and (3) for fundraising purposes, or if we seek to sell your medical information. If you
sign a written authorization allowing us to disclose medical information about you, you may later revoke
(or cancel) your authorization in writing (except in very limited circumstances related to obtaining
insurance coverage). If you would like to revoke your authorization, you may write us a letter revoking
your authorization. If you revoke your authorization, we will follow your instructions except to the extent
that we have already relied upon your authorization and taken some action.
YOU HAVE RIGHTS WITH RESPECT
TO MEDICAL INFORMATION ABOUT YOU
You have several rights with respect to medical information about you. This section of the Notice will
briefly mention each of these rights. If you would like to know more about your rights, please contact our
Privacy Officer at this Clinic’s main phone number.
1. Right to a Copy of This Notice
You have a right to have a paper copy of our Notice of Privacy Practices at any time. In addition, a copy
of this Notice will always be posted in our waiting area. If you would like to have a copy of our Notice, ask
the receptionist for a copy or contact our Privacy Officer at this Clinic’s main phone number.
2. Right of Access to Inspect and Copy
You have the right to inspect (which means see or review) and receive a copy of medical information
about you that we maintain in certain groups of records. If we maintain your medical records in an
Electronic Health Record (EHR) system, you may obtain an electronic copy of your medical records. You
may also instruct us in writing to send an electronic copy of your medical records to a third party. If you
would like to inspect or receive a copy of medical information about you, you must provide us with a
request in writing.
We may deny your request in certain circumstances. If we deny your request, we will explain our reason
for doing so in writing. We will also inform you in writing if you have the right to have our decision
reviewed by another person.
If you would like a copy of the medical information about you, we will charge you a fee to cover the costs
of the copy. Our fees for electronic copies of your medical records will be limited to the direct labor costs
associated with fulfilling your request.
We may be able to provide you with a summary or explanation of the information. Contact our Privacy
Officer for more information on these services and any possible additional fees.
3. Right to Have Medical Information Amended
You have the right to have us amend (which means correct or supplement) medical information about you
that we maintain in certain groups of records. If you believe that we have information that is either
inaccurate or incomplete, we may amend the information to indicate the problem and notify others who
have copies of the inaccurate or incomplete information. If you would like us to amend information, you
must provide us with a request in writing and explain why you would like us to amend the information.
We may deny your request in certain circumstances. If we deny your request, we will explain our reason
for doing so in writing. You will have the opportunity to send us a statement explaining why you disagree
with our decision to deny your amendment request and we will share your statement whenever we
disclose the information in the future.
4. Right to an Accounting of Disclosures We Have Made
You have the right to receive an accounting (which means a detailed listing) of certain disclosures that we
have made for the previous six (6) years. If you would like to receive an accounting, you may send us a
letter requesting an accounting or contact our Privacy Officer.
The accounting will not include several types of disclosures, including disclosures for treatment, payment
or health care operations. If we maintain your medical records in an Electronic Health Record (EHR)
system, you may request that include disclosures for treatment, payment or health care operations. The
accounting will also not include disclosures made prior to April 14, 2003.
If you request an accounting more than once every twelve (12) months, we may charge you a fee to
cover the costs of preparing the accounting.
5. Right to Request Restrictions on Uses and Disclosures
You have the right to request that we limit the use and disclosure of medical information about you for
treatment, payment and health care operations. We are not required to agree with your request for a restriction on the use and disclosure of your medical information. However, under federal law, we must
agree to your request and comply with your requested restriction(s) if:
1. Except as otherwise required by law, the disclosure is to a health plan for purpose of carrying
out payment or health care operations (and is not for purposes of carrying out treatment);
2. The medical information pertains solely to a health care item or service for which the health
care provided involved has been paid out-of-pocket in full.
Once we agree to your request, we must follow your restrictions (except if the information is necessary for
emergency treatment). You may cancel the restrictions at any time. In addition, we may cancel a
restriction at any time as long as we notify you of the cancellation and continue to apply the restriction to
information collected before the cancellation.
6. Right to Request Confidential Communication or an Alternative Method of Contact
You have the right to request to be contacted at a different location or by a different method. For
example, you may prefer to have all written information mailed to your work address rather than to your
We will agree to any reasonable request for confidential communications or alternative methods of
contact. We will not ask you the reason for the request. If you would like to request a confidential
communication or an alternative method of contact, you must provide us with a request in writing.
YOU MAY FILE A COMPLAINT
ABOUT OUR PRIVACY PRACTICES
If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies
or procedures, you may file a written complaint either with us or with the federal government.
We will not take any action against you or change our treatment of you in any way if you file a
To file a written complaint with us, you may bring your complaint directly to our Privacy Officer, or you
may mail it to our Clinic Address, care of HIPAA Privacy Officer.
To file a written complaint with the federal government, please use the following contact information:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
Toll-Free Phone: (800) 368-1019
TDD Toll-Free: (800) 537-7697