Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Uses and Disclosures
Here are some examples of how we might have to use or
disclose your health care information:
Your chiropractor or a staff member may have to disclose
your health information including all of your clinical records to another
health care provider or a hospital if it is necessary to refer you to them
for diagnosis, assessment, or treatment of your health condition.
Our insurance and billing staff may have to disclose your
examination and treatment records and your billing records to another party,
such as an insurance carrier, an HMO, a 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 his/her practice.
Your chiropractor and members of the practice staff may
need to use your name, address, phone number, and your 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
will be left on your answering machine.
You have the right to refuse to give us authorization to
contact you to provide appointment reminders, information about treatment
alternatives, or other health related information. 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, or other health related information at any time.
Permitted uses and 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 the law.
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We are permitted to use or disclose your health
information to an appropriate law enforcement authority if the disclosure is
necessary to prevent or lesson 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 services from us. We may also mail
you information regarding your health or about the status of your account. We
will do our best to accommodate any reasonable request if you would like to
receive information about your health or the services that we provide at a
place other than your home or, if you would like the information in a
different form. To help us respond to your needs, please make any request in
writing.
Your right to inspect and copy your health information
You have the right to inspect and/or copy 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 reasonable 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 based 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 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 is a fee for any additional requests during the
next 12 months. When you make your request we will tell you 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 by e-mail,
you may request a paper copy of this notice at any time.
Our duties
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.
Re-disclosure
Information that we use or disclose may be subject to
re-disclosure by the person to whom we provide the information and may no
longer be protected by the federal privacy rules.
Your right to complain
You may complain 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:
Bakke Chiropractic Clinic
312 East North Street
DeForest, WI 53532
(608) 846-3337
Appointment Reminders and Health Care Information
Authorization
Your chiropractor and members of the practice staff may need
to use your name, address, phone number, and your clinical records to contact
you with appointment reminders, information about treatment alternatives, or
other health related information that may be of interest to you. If this contact
is made by phone and you are not available, a message will be left on your
answering machine or with the person answering the phone. By signing this form,
you are giving us authorization to contact you with these reminders and
information and to leave messages on your answering machine or with individuals
at your home or place of employment.
You may restrict the individuals or organizations to which
your health care information is released or you may revoke your authorization to
us 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 the 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, or other health related information at any time.
This notice is effective as of April 1st, 2003
. This authorization will expire seven years after the date on which you
last received services from us.
I authorize you to use or disclose my health information in
the manner described above. I am also acknowledging that I have received a copy
of this authorization.
________________________________________________
_______________________
Patient Name
Printed Date
________________________________________________
_______________________
Patient Signature
Authorized Provider Representative
________________________________________________
_______________________________
Personal Representative Printed
Personal Representative Signature
Description of personal representative’s authority to act for
the patient.
Consent for Use or Disclosure of Health Information
Our Privacy Pledge
We are very concerned with protecting your privacy. While the
law requires us to give you this disclosure, please understand that we have, and
always will, respect the privacy of your health information.
There are several circumstances in which we may have to use
or disclose your health care information.
We may have to disclose your health information to another
health care provider or a hospital if it is necessary to refer you to them for
the diagnosis, assessment, or treatment of your health condition.
We may have to disclose your health information and billing
records to another party if they are potentially responsible for the payment
of your services.
We may need to use your health information within our
practice for quality control or other operational purposes.
Along with this consent form, you will be given a copy of our
privacy notice that describes our privacy policies in detail. You have the right
to review that notice before you sign this consent form. We reserve the right to
change our privacy practices as described in that notice. If we make a change to
our privacy practices, we will notify you in writing when you come in for
treatment or by mail.
Your right to limit uses or disclosures
You have the right to request that we do not disclose your
health information to specific individuals, companies, or organizations. If you
would like to place any restrictions on the use or disclosure of your health
information, please let us know in writing. We are not required to agree to your
restrictions. However, if we agree with your restrictions, the restriction is
binding on us.
Your right to revoke your authorization
You may revoke any of your authorizations at any time;
however, your revocation must be in writing. 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.
I have read your consent policy and agree to its terms. I am
also acknowledging that I have received a copy of this consent form and a copy
of your privacy notice (Notice of Privacy Practices for Protected Health
Information).
_________________________________________
________________________________
Printed Name
Authorized Provider Representative
_________________________________________
_____________________
Signature
Date
This page updated 4/13/2003
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