Crosby Chiropractic & Acupuncture Centre
PATIENT PRIVACY NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY
The office of Crosby Chiropractic Centre, (referred to hereafter as the or this "office") is committed to protecting your
personal medical information. The creation of a record detailing the care and services you recieve helps this office
to provide you with quality health care and complies with this office's medical records retention requirements. This notice
applies to the medical records maintained by this office and it specifically details the ways in which your medical information may be used and disclosed
to third parties. This notice also details your individual rights regarding your medical records.
- This office may use and/or disclose your medical information consistent with valid consent gained by you for purposes of
- Treatment - to order to provide you with the health care you require, this office will provide your medical information
to those health care professionals, whether on this office's staff or not, directly involved in your care so that they may understand
your medical condition and need.
- Payment - In order to get paid for services provided, this office will provide your medical information,
directly or through a billing service, to appropriate third party payors, pursuant to their billing prayment
requirements. For example, this office may need to provide the Medicare program with information about
the srvices you received so that this office can be properly reimbursed. This office may also need to tell
your insurance plan about treatment so it can be determined whteher or not your plan will cover the treatment.
- Health Care Operations- In order to gain an overall view of various elements of this office's operations,
individual medical information may be collected, compiled and disseminated. For example, this office may
utilize your medical information in order to evaluate the performance of our personnel in providiing care to you.
- This office may use and/or disclose your medical information, without written consent in the following instances:
- De-identified Information - Information that is not individually identifiable or that has had all personally identifying information
removed, in accordance with applicable laws, may be freely disclosed by this office.
- Business Associate - If this office obtains satisfactory written assurance from the business associate, in accordance
with applicable laws, that the business associate will appropriately safeguard the protected information. For example, a
business associate is not a member of the health care provider's workforce, but provides certain services for the practitioner
involving the use and/or disclosure of private health information.
- Personal Representative - If under applicable state law a person has authority to represent you in making decisions related
to your health care, information may be disclosed to that person without your written consent.
- Other uses and/or disclosures will be made only with your written aurthorization and you may revoke any authorization
as set forth in this notice.
- Your individual rights- You have the right to:
- Revoke any authorization in writing at any time - To request a revocation, please submit written request to this office's Privacy Officer, as set forth in Section 4(i) below;
- Request restriction on certain uses and/or disclosure as provided by law; however, this office is not
obligated to agree to any requested restrictions - To request restrictions, please submit a written request to
this office's Privacy Officer, as set forth in Section 4(i) below. In your written request, you must inform
this office what information you want to limit, whether you want to limit this office's use or disclosure, or
both, and to whom you want the limits to apply. If this office agrees to your request, we will comply with
the request unless the information is needed in order to provide you with emergency treatment;
- Receive confidential communications of protected health information as required by law to request confidential
communication, you must make your request in writing to this office's Privacy Officer, as set forth in Section 4(i) below.
We will accommodate all reasonable requests. your request must specify how and where you wish to be contacted;
- Inspect and copy protected health information as provided by law. This right includes access to medical
and billing records. To inspect and copy health informaton, please submit a written request to this office's
Privacy Officer, as set forth in Section 4(i) below. This office can charge you a fee for the cost of copying, mailing
or other supplies associated with your request. This office may deny you access to medical informaion, but you have a right to
have this denial reviewed as will be set forth more fully in the written denial notice;
- Amend incorrect or incomplete protected information as provided by law- To request an amendment,
please submit a written request to this office's Privacy Officer, as set forth in Section 4(i) below. You provide a
reason that supports your request for amendment(s). This office may deny your request if it is not in writing, if you do
not provide a reason to support your request, if the information to be ammended was not created by this office (unless the individual or entity that
created the information is no longer available), if the information is not part of the medical inforamtion maintained by the office, if
the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate
and complete;
- Recieve an accounting of disclosure (but not the users) of protected information as provided by law
To request an accounting, please submit a written request to this office's Privacy Officer, as set forth in
Section 4(i) below. The request must state a time period which may not be longer than 6 years and dmay not
include dates before April 14, 2003. The request should indicate in what form you want the list
(such as a paper or electronic copy). The first list request withing a 12 month persiod will be free, but this office will charge you for the costs of
providing addtional lists. This office will notify you of the costs involved and yo can decided to withdraw or modify your request before any costs are incurred;
- To receive a paper copy of this notice from this office upon request to this office's Privacy Officer, as set forth in Section 4(i) below:
- To complain to this office or to the Secretary of HHS if you believe your privacy rights have been violated. To file a complaint, please
contact this office's Privacy Officer, as set forth in Section 4(i) below. All complaints must be in writing; and
- To obtain more information, or have your questions about your rights answered, you may contact this office's Privacy
Policy Officer, (Teresa Heaton, 636-928-5588)
- Emergency Situations - For the purpose of obtaining or rendering emergency treatment to you, if the office attempts to obtain consent but is unable to do so; to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating your care with such entities in an emergency situation;
- Communication Barriers - If, due to substantial communication barriers or inability to communicate, this office has been unable to obtain consent and this office determines, in the exercise of its professional judgment, that your consent to receive treatment is clearly inferred for the circumstances;
- Involvement in Care or Payment - In accordance with applicable laws, disclosure may be made to your family members, other relatives, close personal friends and/or any other person identified by you, of such information that is relevant to the person's involvement with your care or payment related to your health care;
- Notification - In order to notify or assist in the notification of a family member, a personal representative or another person responsible for your care of your location of general condition;
- Required by Law - When and to the extent that such disclosure is required by law, complies with and is limited to the relevant requirements of such law;
- Criminal Conduct - To a law enforcement official, that this office believes in good faith contributes evidence or criminal conduct that occurred on the office premises;
- Threat to Health and/or Safety - If it is necessary to prevent or lesson serious and imminent threat to the health and/or safety of a person or the public, in accordance with applicable laws;
- Appointment Reminders, Treatment Alternatives, and Health Related Benefits - In order to provide you with appointment reminders, or information about treatment alternatives or other health related benefits and services that may be of interest to you. These may be by telephone, e-mail, fax or mail;
- Military and Veterans - If you are a member of the armed forces, as required by military command authorities;
- Worker's Compensation - In order to provide information about you to worker's compensation programs designed to provide benefits for work-related injuries;
- Public Health Risks - In order to provide or control disease, injury and disability and to report child abuse or neglect
- Public Health Oversight Activities - In order to provide information to a Health Oversight agency, such as the Missouri Department of Health, for activities authorized by law, including inspections, investigations, audits and licensure;
- Lawsuits and Disputes - In order to comply with a court or administrative order in connection with a lawsuit or dispute
- Corners, Medical Examiners and Funeral Directors - In order to provide information to a coroner, medical examiner or funeral director for purposes or identification of an individual, the determination of cause of death and for burial purposes; and
- National Security and Intelligence Activities - In order to provide authorized governmental officials with necessary intelligence information for national security activities and purposes authorized by law.
- Office Rights and Requirements - This office:
- Is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected information;
- is required to abide by the terms of this notice;
- Reserves the right to change the terms of this notice and to make the new notice provisions effective for all protected information that it maintains;
- Will: Give to you, and you will be required to sign, a receipt for any revised notice.
- Will not retaliate against you for filing a complaint.
- This original notice is in effect as of 10/31/2007
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