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.
If
you have any questions about this Notice please contact our Privacy
Contact
or any staff member in our office.
Our
Privacy Contact is Jeffrey-Richard..Kotchounian.
This
Notice of Privacy Practices describes how we may use and disclose your
protected health information to carry out your treatment, collect
payment
for your care and manage the operations of this clinic. It
also describes our policies concerning the use and disclosure of this
information
for other purposes that are permitted or required by law. It
also describes your rights to access and control your protected health
information. “Protected health information”
is information about you, including demographic information that may
identify
you, that relates to your past, present or future physical or mental
health
or condition and related health care services.
We
are required by federal law to abide by the terms of this Notice of
Privacy
Practices. We may change the terms
of our notice, at any time. The new
notice will be effective for all protected health information that we
maintain
at that time. You may obtain revisions
to our Notice of Privacy Practices by accessing our web site www.deerfieldchiropractic.com/pp,
calling the office and requesting that a revised copy be sent to you in
the mail or asking for one at the time of your next appointment.
1.
Uses and Disclosures of Protected Health Information
Uses
and Disclosures of Protected Health Information Based Upon Your Implied
Consent
By
applying to be treated in our office, you are implying consent to the
use
and disclosure of your protected health information by your physician,
our office staff and others outside of our office that are involved in
your care and treatment for the purpose of providing health care
services
to you. Your protected health information
may also be used and disclosed to bill for your health care and to
support
the operation of the physicians practice.
Following
are examples of the types of uses and disclosures of your protected
health
care information we will make, based on this implied consent. These
examples are not meant to be exhaustive but to describe the types of
uses
and disclosures that may be made by our office.
Treatment:
We will use and disclose your protected health information to provide,
coordinate, or manage your health care and any related services. This
includes the coordination or management of your health care with a
third
party that has already obtained your permission to have access to your
protected health information. For
example, we would disclose your protected health information, as
necessary,
to another physician who may be treating you. Your
protected health information may be provided to a physician to whom you
have been referred to ensure that the physician has the necessary
information
to diagnose or treat you.
In
addition, we may disclose your protected health information from time
to time
to another physician or health care provider (e.g., a specialist or
laboratory)
who, at the request of your physician, becomes involved in your care by
providing assistance with your health care diagnosis or treatment to
your
physician.
Payment:
Your protected health information will be used, as needed, to obtain
payment
for your health care services. This
may include certain activities that your health insurance plan may
undertake
before it approves or pays for the health care services we recommend
for
you such as; making a determination of eligibility or coverage for
insurance
benefits, reviewing services provided to you for medical necessity, and
undertaking utilization review activities. For
example, obtaining approval for chiropractic spinal adjustments may
require
that your relevant protected health information be disclosed to the
health
plan to obtain approval for those services.
Health care
Operations:
We may use or disclose, as needed, your protected health information in
order to support the business activities of your physicians practice.
These
activities include, but are not limited to, quality assessment
activities,
employee review activities and training of chiropractic students.
For
example, we may disclose your protected health information to
chiropractic
interns or precepts that see patients at our office. In
addition, we may use a sign-in sheet at the registration desk where you
will be asked to sign your name and indicate your physician.
Communications
between you and the doctor or his assistants may be recorded to assist
us in accurately capturing your responses. We
may also call you by name in the waiting room when your physician is
ready
to see you. We may use or disclose
your protected health information, as necessary, to contact you to
remind
you of your appointment.
We
will share your protected health information with third party “business
associates” that perform various activities (e.g., billing,
transcription
services) for the practice. Whenever
an arrangement between our office and a business associate involves the
use or disclosure of your protected health information, we will have a
written contract with that business associate that contains terms that
will protect the privacy of your protected health information.
We
may use or disclose your protected health information, as necessary, to
provide you with information about treatment alternatives or other
health related
benefits and services that may be of interest to you. We
may also use and disclose your protected health information for other
marketing
activities. For example, your name
and address may be used to send you a newsletter about our practice and
the services we offer. We may also
send you information about products or services that we believe may be
beneficial to you. You may contact
our Privacy Contact to request that these materials not be sent to
you.
Uses
and Disclosures of Protected Health Information That May Be Made With
Your
Written Authorization
Other
uses and disclosures of your protected health information will be made
only with your written authorization, unless otherwise permitted
or required by law as described below.
For
Example, with your written, signed authorization, we may use your
demographic
information and the dates that you received treatment from your
physician,
as necessary, in order to contact you for fundraising activities
supported
by our office. With your written,
signed authorization, we may use your photograph on a “Birthday Board”
or other display in our waiting room or your testimonial story in a
folder
kept in the waiting room for patient education purposes.
You
may revoke any of these authorizations, at any time, in writing, except
to the extent that your physician or the physicians practice has taken
an action in reliance on the use or disclosure indicated in the
authorization.
Other
Permitted and Required Uses and Disclosures That May Be Made With Your
Authorization or Opportunity to Object
In
the following instance where we may use and disclose your protected
health
information, you have the opportunity to agree or object to the use or
disclosure of all or part of your protected health information. If
you are not present or able to agree or object to the use or disclosure
of the protected health information, then your physician may, using
professional
judgment, determine whether the disclosure is in your best interest. In
this case, only the protected health information that is relevant to
your
health care will be disclosed.
Others
Involved in Your Health care:
Unless you object, we may disclose to a member of your family, a
relative,
a close friend or any other person you identify, your protected health
information that directly relates to that persons involvement in your
health care. If you are unable to
agree or object to such a disclosure, we may disclose such information
as necessary if we determine that it is in your best interest based on
our professional judgment. We may
use or disclose protected health information to notify or assist in
notifying
a family member, personal representative or any other person that is
responsible
for your care of your location, general condition or death. Finally,
we may use or disclose your protected health information to an
authorized
public or private entity to assist in disaster relief efforts and to
coordinate
uses and disclosures to family or other individuals involved in your
health
care.
Other
Permitted and Required Uses and Disclosures That May Be Made Without
Your
Consent, Authorization or Opportunity to Object
We
may use or disclose your protected health information in the following
situations without your consent or authorization. These situations
include:
Required
By Law:
We may use or disclose your protected health information to the extent
that the use or disclosure is required by law. The use or disclosure
will
be made in compliance with the law and will be limited to the relevant
requirements of the law. You will be notified, as required by law, of
any
such uses or disclosures.
Public
Health:
We may disclose your protected health information for public health
activities
and purposes to a public health authority that is permitted by law to
collect
or receive the information. The disclosure will be made for the purpose
of controlling disease, injury or disability. We may also disclose your
protected health information, if directed by the public health
authority,
to a foreign government agency that is collaborating with the public
health
authority.
Communicable
Diseases:
We may disclose your protected health information, if authorized by
law,
to a person who may have been exposed to a communicable disease or may
otherwise be at risk of contracting or spreading the disease or
condition.
Health
Oversight:
We may disclose protected health information to a health oversight
agency
for activities authorized by law, such as audits, investigations, and
inspections.
Oversight agencies seeking this information include government agencies
that oversee the health care system, government benefit programs, other
government regulatory programs and civil rights laws.
Abuse
or Neglect:
We may disclose your protected health information to a public health
authority
that is authorized by law to receive reports of child abuse or neglect.
In addition, we may disclose your protected health information if we
believe
that you have been a victim of abuse, neglect or domestic violence to
the
governmental entity or agency authorized to receive such information.
In
this case, the disclosure will be made consistent with the requirements
of applicable federal and state laws.
Food
and Drug Administration:
We may disclose your protected health information to a person or
company
required by the Food and Drug Administration to report adverse events,
product defects or problems, biologic product deviations, track
products;
to enable product recalls; to make repairs or replacements, or to
conduct
post marketing surveillance, as required.
Legal
Proceedings:
We may disclose protected health information in the course of any
judicial
or administrative proceeding, in response to an order of a court or
administrative
tribunal (to the extent such disclosure is expressly authorized), in
certain
conditions in response to a subpoena, discovery request or other lawful
process.
Law
Enforcement:
We may also disclose protected health information, so long as
applicable
legal requirements are met, for law enforcement purposes. These
law enforcement purposes include (1) legal processes and otherwise
required
by law, (2) limited information requests for identification and
location
purposes, (3) pertaining to victims of a crime, (4) suspicion that
death
has occurred as a result of criminal conduct, (5) in the event that a
crime
occurs on the premises of the practice, and (6) medical emergency (not
on the Practices premises) and it is likely that a crime has
occurred.
Coroners,
Funeral Directors, and Organ Donation:
We may disclose protected health information to a coroner or medical
examiner
for identification purposes, determining cause of death or for the
coroner
or medical examiner to perform other duties authorized by law. We
may also disclose protected health information to a funeral director,
as
authorized by law, in order to permit the funeral director to carry out
their duties. We may disclose such
information in reasonable anticipation of death. Protected health
information
may be used and disclosed for cadaveric organ, eye or tissue donation
purposes.
Research:
We may disclose your protected health information to researchers when
an
institutional review board has approved their research and that review
board has reviewed the research proposal and established protocols to
ensure
the privacy of your protected health information.
Criminal
Activity:
Consistent with applicable federal and state laws, we may disclose your
protected health information, if we believe that the use or disclosure
is necessary to prevent or lessen a serious and imminent threat to the
health or safety of a person or the public. We may also disclose
protected
health information if it is necessary for law enforcement authorities
to
identify or apprehend an individual.
Military
Activity and National Security:
When the appropriate conditions apply, we may use or disclose protected
health information of individuals who are Armed Forces personnel (1)
for
activities deemed necessary by appropriate military command
authorities;
(2) for the purpose of a determination by the Department of Veterans
Affairs
of your eligibility for benefits, or (3) to foreign military authority
if you are a member of that foreign military services. We may also
disclose
your protected health information to authorized federal officials for
conducting
national security and intelligence activities, including for the
provision
of protective services to the President or others legally
authorized.
Workers’
Compensation:
We may disclose your protected health information, as authorized, to
comply
with workers’ compensation laws and other similar legally established
programs.
Inmates:
We may use or disclose your protected health information if you are an
inmate of a correctional facility and your physician created or
received
your protected health information in the course of providing care to
you.
Required
Uses and Disclosures:
Under the law, we must make disclosures to you and when required by the
Secretary of the Department of Health and Human Services to investigate
or determine our compliance with the requirements of Section 164.500
et.
seq.
2.
Your Rights
Following
is a statement of your rights with respect to your protected health
information
and a brief description of how you may exercise these rights.
You
have the right to inspect and copy your protected health information.
This
means you may inspect and obtain a copy of protected health information
about you that is contained in a designated record set for as long as
we
maintain the protected health information. A
“designated record set” contains medical and billing records and any
other
records that your physician and the practice uses for making decisions
about you.
Under
federal law, however, you may not inspect or copy the following
records;
psychotherapy notes; information compiled in reasonable anticipation
of,
or use in, a civil, criminal, or administrative action or proceeding,
and
protected health information that is subject to law that prohibits
access
to protected health information. Depending
on the circumstances, a decision to deny access may be reviewable. In
some circumstances, you may have a right to have this decision
reviewed. Please
contact our Privacy Contact if you have questions about access to your
medical record.
You
have the right to request a restriction of your protected health
information. This
means you may ask us not to use or disclose any part of your protected
health information for the purposes of treatment, payment or health
care
operations. You may also request
that any part of your protected health information not be disclosed to
family members or friends who may be involved in your care or for
notification
purposes as described in this Notice of Privacy Practices. Your
request must be in writing and state the specific restriction requested
and to whom you want the restriction to apply.
Your
physician is not required to agree to a restriction that you may
request. If
physician believes it is in your best interest to permit use and
disclosure
of your protected health information, your protected health information
will not be restricted. If your
physician does agree to the requested restriction, we may not use or
disclose
your protected health information in violation of that restriction
unless
it is needed to provide emergency treatment. With
this in mind, please discuss any restriction you wish to request with
your
physician. You may request a restriction
by presenting your request, in
writing to the staff member identified as “Privacy Contact” at the top
of this form. A simple sentence,
“Do not use my PHI (Protected Health Information) for education of
Chiropractic
Students.” or “Do not send any communications to my home address. ”Sign
and date your request. Ask that the
staff provide you with a photocopy of your request initialed by them.
This
copy will serve as your receipt.
You
have the right to request to receive confidential communications from
us
by alternative means or at an alternative location. We
will accommodate reasonable requests. We
may also condition this accommodation by asking you for information as
to how payment will be handled or specification of an alternative
address
or other method of contact. We will
not request an explanation from you as to the basis for the request.
Please
make this request in writing to our Privacy Contact.
You
may have the right to have your physician amend your protected health
information. This
means you may request an amendment of protected health information
about
you in a designated record set for as long as we maintain this
information. In
certain cases, we may deny your request for an amendment .If
we deny your request for amendment, you have the right to file a
statement
of disagreement with us and we may prepare a rebuttal to your statement
and will provide you with a copy of any such rebuttal. Please
contact our Privacy Contact to determine if you have questions about
amending
your medical record.
You
have the right to receive an accounting of certain disclosures we have
made, if any, of your protected health information. This
right applies to disclosures for purposes other than treatment, payment
or health care operations as described in this Notice of Privacy
Practices. It
excludes disclosures we may have made to you, for a facility directory,
to family members or friends involved in your care, pursuant to a duly
executed authorization or for notification purposes. You
have the right to receive specific information regarding these
disclosures
that occurred after April 14, 2003. You
may request a shorter time frame. The right to receive this information
is subject to certain exceptions, restrictions and limitations.
You
have the right to obtain a paper copy of this notice from us,
upon request, even if you have agreed to accept this notice
electronically.
3.
Complaints
You
may complain to us or to the Secretary of Health and Human Services if
you believe your privacy rights have been violated by us. You may file
a complaint with us by notifying our privacy contact of your complaint.
We will not retaliate against you for filing a complaint.
Our
Privacy Contact is Jeffrey Kotchounian.You
may contact our Privacy Contact, or any staff member, including your
physician
at (810) 793-7376 or www.deerfieldchiropractic.com/pp for
further information about the complaint process.
Office visits are by appointment only. Dr. Kotchounian does not have a pager or an answering service. If an emergency should arise during off hours contact your primary care physician for health care at that time or go to the emergency room for help. You may leave a message at our office and we will contact you as soon as we can. If an emergency should arise while the office is open, we will try our best to service you in a timely manner.
This
notice was published and becomes effective on January
24, 2003