Privacy Policy Form

Chaney Chiropractic Center Privacy Policy Form PDF



Notice of Privacy Practices

We care about our patients’ privacy and strive to protect the confidentiality of your medical information at this practice.  New federal legislation requires that we issue this official notice of our privacy practices.  You have the right to the confidentiality of your medical information, and this practice is required by law to maintain the privacy of that information.

This practice is required to abide by the terms of the Notice of Privacy Practices currently in effect, and to provide notice of its legal duties and privacy practices with respect to protected health information.  If you have any questions about this Notice, please contact the Privacy Officer at this practice.

Who will follow this notice?

Any health care professional authorized to enter information into your medical record, all employees, staff and other personnel at this practice who may need access to your information must abide by this Notice.  All subsidiaries, business associates (e.g. a billing service), sites and location of this practice may share medical information with each other for treatment, payment purposes or heath car operation as stated in this Notice.  Except where treatment is involved, only the minimum necessary information needed to accomplish the task will be shared.

How We May Use and Disclose Medical Information About You

The following categories describe different ways that we may use and disclose medical information without your specific consent or authorization.  Examples are provided for each category of uses or disclosures.  Not all possible uses or disclosures are listed.

For Treatment.  We may use medical information about you to provide you with medical treatment or services.  Example: In treating you for a specific condition, we may need to know if you have allergies or prior injuries or surgeries that could influence our treatment process.

For Payment.  We may use and disclose medical information about you so that the treatment and services you receive from us may be billed and payment collected from you, an insurance company or a third party.  Example:  We may need to send your protected health information, such as your name, address, office visit date, and codes identifying your diagnosis and treatment to your insurance company for payment.

For Health Care Operations.  We may use and disclose medical information about you for health care operations to assure that you receive quality care.  Example:  We may use medical information to review our treatment and services and evaluate the performance of our staff in caring for you.

    Other Uses or Disclosures That Can be Made Without Your Consent or Authorization

·          As required during an investigation by law enforcement agencies

·          To avert a serious threat to public health or safety

·          As required by military command authorities for their medical records

·          To worker’s compensation or similar programs for processing of claims

·          In response to a legal proceeding

·          To a coroner or medical examiner for identification of a body

·          If an inmate, to the correctional institution or law enforcement official

·          As required by the US Food and Drug Administration (FDA)

·          Other healthcare providers treatment activities

·          Other covered entities’ and providers’ payment activities

·          Other covered entities’ healthcare operations activities (to the extent permitted under HIPPA)

·          Uses and disclosures required by law

·          Uses and disclosures in domestic violence or neglect situations

·          Health oversight activities

·          Other public health activities

We may contact you to provide appointment reminders or information about treatment and other health related benefits and services that may be of interest to you.

Uses and Disclosures of Protected Health Information Requiring Your Written Authorization

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization.  If you give us authorization to use or disclose medial information about your, you may revoke that authorization, in writing, at any time.  IF you revoke your authorization, we will thereafter no longer use or disclose medical information about you for the reasons covered by your written authorization.  We are unable to take back any disclosures we have already made with your authorization, and we are required to retain our records of the care we have provided you.


Your Individual Rights Regarding:

Disclosures and Changes to Your Medical Information

Right to Request Restrictions.  You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or heath care operations or to someone who is involved in your care or the payment of your care.  We are not required to agree to your request.  If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.  To request restrictions, you must submit your request in writing to the Privacy Officer at this practice.  In your request you must tell us what information you want to limit.

Right to an Accounting of Non-Standard Disclosures.  You have the right to request a list of the disclosures we made of medical information about you.  To request this list, you must submit your request in writing to the Privacy Officer at this practice.  Your request must state the time period for which you want to receive a list of disclosures that is no longer than six years, and may not include dates before April 14, 2003.  Your request should indicate in what form you want the list (example: paper or electronically).  The first list you request within a 12-month period will be free.  For additional lists, we reserve the right to charge you for the cost of providing the list.

Right to Amend.  If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept.  To request an amendment, your request must be made in writing and submitted to the Privacy Officer at this practice.  In addition you must provide a reason that supports your request.  We may deny your request for an amendment if it is not in writing or does not include a reason to support the request.  In addition we may deny your request if the information was not created by us, is not part of the medical information kept at this practice, is not part of the information which you would be permitted to inspect and copy, or which we deem to be accurate and complete.  If we deny your request for amendment, you have the right to file a statement of disagreement with us.  We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.  Statements of disagreement and any corresponding rebuttals will be kept on file and sent out with any future authorized requests for information pertaining to the appropriate portion of your record.

Your Access to Medical Information

Right to Inspect and Copy.  You have the right to inspect and copy medical information that may be used to make decisions about your care.  Usually this includes medical and billing records but does not include psychotherapy notes, information compiled for use in a civil, criminal or administrative action or proceeding, and protected health information to which access is prohibited by law.  To inspect and copy medical information that may be used to make decisions about your, you must submit your request in writing to the privacy officer at this practice.  If you request a copy of the information, we reserve the right to charge a fee for the costs of copying, mailing or other supplies associated with your request.  We may deny your request to inspect and copy in certain very limited circumstances.  If you are denied access to medical information, you may request that the denial be reviewed.  Another licensed heath care professional chosen by this practice will review your request and the denial.  The person conducting the review will not be that person who denied your request.  We will comply with the outcome of the review.

Right to a Paper Copy of This Notice.  You have the right to a paper copy of this Notice at any time.  Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy.  To obtain a paper copy of the current Notice, please request one in writing from the Privacy Office at this practice.

Right to Request Confidential Communications.   You have the right to request how we should send communications to you about medical matters, and where you would like those communication sent.  To request confidential communication, you must make your request in writing to the Privacy Officer at this practice.  We will not ask you the reason for your request.  We will accommodate all reasonable requests.  Your request must specify how or where you wish to be contacted.  We reserve the right to deny a request if it imposes an unreasonable burden on the practice.

Complaints.  If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer at this practice or with the Secretary of the Department of Health and Human Services.  All complains must be submitted in writing.  You will not be penalized or discriminated against for filing a complaint.

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