Hipaa Policy

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and 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 and that relates to your past, present, or future physical or mental health or condition and released healthcare services.
1.Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purposes of providing healthcare services to you, to pay your healthcare bills, to support the operation of the physician’s practice, and any other use requested by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care for you. For example, 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.
Payment: Your protected health information will be used, as needed, to obtain payment for your healthcare services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as needed, your protected health information to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. Inc 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. 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 may use or disclose your protected health information in the following situations without your authorization. These situations include as Required By Law, Public Health issues as required by law. Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: 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.
Substance Use Disorder Records Federal law provides additional privacy protections for records related to substance use disorder (SUD) treatment under 42 CFR Part 2.
Our clinic does not provide substance use disorder treatment services and does not maintain records for the purpose of diagnosing or treating substance use disorders.
If we ever receive substance use disorder records from another healthcare provider that is subject to these federal protections, we will maintain and use those recorders in accordance with applicable federal and state law, which may impose more stringent restrictions on their use and disclosure than HIPAA alone.
Certain wellness or neurological services provided by our clinic are not intended to diagnose or treat substance use disorders or serious mental health conditions.
Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
2.Your Rights: Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. 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.
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 healthcare 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 state the specific restriction requested and to whom you want the restrictions to apply.
Your physician is not required to agree to restriction that you may request. If a 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. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. 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 alternatively i.e., electronically.
You have the right to have your physician amend your protected health information. 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.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdrawal as provided in this notice.
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 private contact of your complaint.
We will not retaliate against you for filing a complaint.
We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we begin any health care operations, we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information, we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.
1.
This patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow the chiropractor office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.
2.
The patient has the right to examine and obtain a copy of his or her health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is obligated to agree to those restrictions only to the extent they coincide with state and federal law.
3.
A patient’s written consent needs only be obtained one time for all subsequent care given the patient in this office.
4.
The patient may provide a written request to revoke consent at any time during care. This would not affect the use of these records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.
5.
Our office may contact you periodically regarding appointments, treatments, products, services, or charitable work performed by our office. You may choose to opt out of any marketing or fund-raising communications at any time.
6.
For your security and right to privacy, all staff have been trained in patient record’s privacy and privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure you that all your records are not readily available to those who do not need them.
7.
Patients have the right to file a formal complaint with our privacy official and the Secretary of HHS about any possible violations of these policies and procedures without retaliation by this office.
8.
Our office reserves the right to make changes to this notice and to make the new notice provisions effective for all protected health information that it maintains. You will be provided with a new notice at your next visit following any changes.
9.
This notice is effective on the date stated below.
10.
If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care.
11.
I understand that this office treats in an open adjusting area where privacy is limited. I understand that I can meet with the doctor privately in a closed room upon my request. Unless a request is made, it is understood that I will be treated in an open adjusting room.
12.
I understand that at some point in the future if I refer someone to this office, my name and image may appear on a thank you board or other notation(s) throughout this office, that is in plain view of other individuals that are in this office.
This notice was published and becomes effective on/or before March 5th, 2026.
We are required by law to maintain the privacy of and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPPA Compliance Officer in person or by phone at our Main Phone Number.
Please list below the specific persons/class of persons/facilities to whom we are authorized to use or disclose information to about you:
Name:__________________________________________________________ Phone Number: ____________________________
Name:__________________________________________________________ Phone Number: ____________________________
Name:__________________________________________________________ Phone Number: ____________________________
Signature below is only acknowledged that you have received this Notice of our Privacy Practices:
Name of Patient (Signature): _______________________________________________
Print Name: ________________________________________________________
Date: ____________________________________