NOTICE OF PRIVACY PRACTICES & MARKETING AUTHORIZATION
THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Uses and Disclosures
Here are some examples of how we might use or disclose your health care information:
- Your chiropractor or a staff member may disclose your health information including your clinical records to another health care provider or hospital if necessary to refer you to them for diagnosis, assessment, or treatment of your health condition.
- Our insurance and billing staff may disclose your examination and treatment records and/or billing records to another party, such as an insurance carrier, HMO, PPO or your employer if they are potentially responsible for the payment of your services.
- 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 their practice.
- Your chiropractor and members of the practice staff may use your name, address, phone number and 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. If you are not at home to receive an appointment reminder, a message may be left with your answering service.
By signing this form, you are giving us authorization to contact you with these reminders and information and leave messages with your answering service or with individuals at your home or place of employment.
From time to time our practice works with marketing organizations to make you aware of products or services that you may have an interest in. Members of this practice staff may need to use your health information including name, address, phone number or clinical records for the purpose of marketing products and services. We are specifically requesting authorization to use this information for the following purposes: quarterly office newsletters, waiting room x-ray view box, and referral thank-you board.
You may restrict the individuals or organizations to which your health care information is released or you may revoke your authorization at any time; however, your revocation must be in writing and mailed to us at our office address. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. In addition, 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.
Information that we use or disclose based on the authorization you are giving us may be subject to re-disclosure by anyone who has access to the reminder or other information and may no longer be protected by federal privacy rules.
You have the right to refuse to give us this authorization. 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, information that we use to contact you form marketing purposes or other health related information at any time.
Permitted Uses & 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:
- We are permitted to use or disclose your health information to the extent that we are required to do so by applicable federal or state laws.
- We are permitted to use or disclose your health information to a public health authority for a wide range of public health activities when the public health authority is authorized to collect or receive your health information under state or federal law.
- We are permitted to use or disclose your health information to an appropriate government authority if we reasonably believe you are the victim of abuse, neglect or domestic violence.
- We are permitted to use or disclose your health information for state and federal health oversight activities of the health care system and government benefit programs.
- We are permitted to use or disclose your health information in response to a court order or in response to a subpoena, discovery request, or other lawful purpose.
- We are permitted to use or disclose your health information to a law enforcement official as required by laws that require us to report certain types of wounds or physical injuries or to comply with court orders, a grand jury subpoena, or administrative requests authorized by law.
- We are permitted to use or disclose your health information to an appropriate law enforcement authority if the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
- We are permitted to use or disclose your health information to a correctional institution if we provide health care services to you as an inmate.
- We are permitted to use or disclose your health information if we provide health care services to you in an emergency.
- We are permitted to use or disclose your health information if we provide care to you that is related to a work place injury to the extent necessary to comply with Wisconsin’s worker’s compensation laws.
Other than the circumstances described in the preceding 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:
- If we have already released your health information before we receive your request to revoke your authorization.
- 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.
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 care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home, or if you would like the information in a specific form, please advise us in writing as to your preferences and we will do our best to accommodate any reasonable request.
Your Right To Inspect And Copy Your Health Information
You have the right to inspect and/or acquire a printed and/or electronic copy of 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. We may refuse your request if the information is for use in a civil, criminal, or administrative action or proceeding which is anticipated to occur in a time frame reasonably proximate to your request. There may be a cost associated with your request if we must copy information for you.
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 we are permitted to make without your consent or authorization as described above.
- Those disclosures made on an authorization you signed.
- Those disclosures necessary to maintain a directory of the individuals in our facility or to individuals involved with your care.
- Those disclosures made for national security or intelligence purposes.
- Those disclosures made to correctional officers or law enforcement officers.
- 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 may be a fee for any additional requests during the next 12 months. When you make your request we will alert you to 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 electronically, you may request a paper copy of this notice at any time.
We are required by law to maintain the privacy of your health information. We are also required to provide you with this notice of our 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.
Your Right To Complain
You may file a grievance to us or to the Secretary of 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 sent to us at the address listed below.
To Contact Us
If you would like further information about our privacy policies and practices please contact us at:
Radermacher Chiropractic Office
P.O. Box 312
Germantown, WI 53022
This notice is effective as of June 11, 2013.