This notice describes how chiropractic & medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.
I. PROTECTED HEALTH INFORMATION
Natural Arts Chiropractic & Acupuncture, in accordance with the Health Insurance Portability and Accountability Act (HIPPA) Privacy Rule, and applicable state law, is committed to protecting the privacy of your protected health information (PHI). PHI includes information about your health condition and the care and treatment you receive from us. This Notice explains how your PHI may be used and disclosed to third parties, and also details your rights regarding your PHI. We are required by law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing our legal duties and practices with respect to your PHI. We are obligated to notify you promptly if a breach occurs that may have compromised the privacy and security of your PHI.
II. HOW WE MAY LEGALLY USE & DISCLOSE YOUR PHI
We may use/disclose your PHI WITHOUT authorization for:
1. Treatment: We may have to disclose your health information, including all of your clinical records, to another health care provider, health care facility, and/or hospital if it is necessary to refer you to them for diagnosis, assessment, or treatment of your health condition.
2. Payment: We may use and disclose your health information for purposes of receiving payment for treatment and services that you receive. For example, our insurance and billing department may disclose your examination, treatment, and / or billing records to other parties, such as an insurance carrier, HMO, PPO, Government programs like Medicare or Medicaid, or your employer, if they are potentially responsible for the payment of your services.
3. Health Care Operations: We may use and disclose your PHI for our own health care operations and the operations of other individuals or organizations involved in providing your care. This is necessary for us to operate and to make sure that our patients receive quality health care.
4. Appointment Reminders: We may use and disclose your PHI to remind you by telephone or mail about appointments you have with us, annual exams, or to follow up on missed or cancelled appointments.
5. Individual(s) Involved in Your Care or Payment for Your Care, and Personal Representative : We may disclose to your designated personal representative, family member, other relative, a close friend, or any other person identified by you certain limited PHI that is directly related to that person’s involvement with your care or payment for your care. We may use or disclose your PHI to notify those persons of your location or general condition. This includes in the event of your death unless you have specifically instructed us otherwise. If you are unable to specifically agree or object, we may use our best judgment when communicating with your family and others.
6. Disaster Relief: We also may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts. This will be done to coordinate information with those organizations in notifying a family member, other relative, close friend or other individual of your location and general condition.
7. De-identified Information: We may use and disclose health information that may be related to your care but does not identify you and cannot be used to identify you.
8. Business Associate: We may use and disclose PHI to one or more of its business associates if we obtain satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI. A business associate is an entity that assists us in undertaking some essential function, such as a billing company that assists the office in submitting claims for payment to insurance companies.
9. Personal Representative: We may use and disclose PHI to a person who, under applicable law, has the authority to represent you in making decisions related to your health care.
10. Emergency Situations: We may use and disclose PHI for the purpose of obtaining or rendering emergency treatment to you provided that we attempt to obtain your consent asap.
11. Public Health and Safety Activities: We may disclose your PHI about you for public health activities and purposes, which includes reporting information to a public health authority that is authorized by law to collect and receive the information. These activities typically include; prevent/control disease injury or disability, report birth/death, report abuse, notify you of recalled products, or to notify you of exposure to disease.
12. Health Oversight, Judicial, and Admin. Proceedings:
We may disclose your PHI to a health oversight agency for activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions. We may disclose your PHI in response to a court or administrative order as long as efforts have been made to tell you about the request.
13. Worker’s Compensation or Personal Injury: Your health information may be used or disclosed in order to comply with laws and regulations related to Worker’s Compensation and Personal Injury cases.
14. Research: We may use and disclose your PHI for research projects that are subject to a special review process. If any researchers are allowed access to information that identifies who you are, will ask for your permission.
We may use/disclose your PHI WITH authorization for:
15. Marketing: We will not use/disclose your PHI for marketing purposes without your express written permission. However, we may contact you with information about products, services or treatment alternatives directly related to your treatment/care.
16. Fundraising: If we wish to raise money for a variety of goodwill causes, we may need to use your health information, such as; your name, address, phone number, and records to contact you to request such assistance with any fund raising efforts. You must authorize us to be able to do this and if you do not consent it will not affect the treatment we provide you or the methods we use to obtain reimbursement for any care provided to you at this facility.
III. YOUR LEGAL RIGHTS REGARDING YOUR PHI
(All requests must be made in written format addressed to our privacy officer at Natural Arts; Dr. Tracy J. Smith)
1. Right to Revoke Authorization: You may revoke any authorization that you made for the use or disclosure of your health information except to the extent that we have already relied on the authorization.
2. Right to Request Restrictions: You have the right to request that we restrict the use/disclosure of information for treatment, payment, or healthcare operations. You may request we restrict information we share about you with a relative/friend of yours. We are not required to agree to your restrictions. However, if we agree to your restrictions, the restrictions are binding on us. If we do not agree to your restrictions, you may drop your request in writing, or you are free to seek health care elsewhere. You also have the right to restrict the disclosure of PHI to a health plan where you paid out of pocket for a health care item or service, and we will abide by this request unless we are legally obligated not to.
3. Right to Receive Confidential Communications: You have the right to request that we communicate your PHI in a certain way or at a certain place. For example, you can ask that we only contact you by mail or at work. If you want to request confidential communications you must do so in writing to our Practice’s Privacy Officer and explain how or where you can be contacted. You do not need to give us a reason for your request. We will accommodate all reasonable requests.
4. Right to Inspect & Copy: You have the right to inspect and copy your health information for seven years from the date that the record was created. You may request your preferred format. We do have the ability to provide this information in an electronic format, via XML. We have the right to charge you a fee for the cost of providing you records.
5. Right to Amend: You have the right to request that we amend your health information for seven years from the date that the record was created. You must provide ample reason to support the change you are requesting. We will review your request, but are not obligated to make the amendment to your record. Either way, you will be notified of our final decision and any further steps you may wish to take.
6. Right to Accounting of Disclosures: You have the right to request that we provide you with an accounting of all disclosures that we have made of your health information in the past 6 years of the date of your request with the exception of disclosures that have been made for; treatment, payment, health care operations, those authorized by you, those for certain government functions, and those needed to run our clinic. The first 12 months is without charge, beyond that, there will be a charge of which you may withdraw or change your request in order to avoid or reduce the fee.
7. Breach of PHI: You will be notified in the event of a breach of the privacy or security of your PHI. This notice will be in the form of an email (if we have this on file) and a 1st class mailing.
8. Right to a Paper Copy of this Notice: You have the right to receive a paper copy of this notice.
9. Right to File a Complaint: You may complain to us if you think we have violated your privacy rights as outlined in this notice. You will not be retaliated against in any way for bringing forth a complaint. Please direct all complaints to the privacy officer listed below in section IV. If you wish, you may also file a complaint with the Secretary of Health and Human Services at DHHS, Office for Civil Rights, 200 Independence Ave., SW Room 509F HHH Building Washington, DC 20201.
IV. NATURAL ARTS CONTACT INFORMATION
Natural Arts Chiropractic & Acupuncture, PLLC
Attention: Privacy Officer
2200 W. 49th St. Ste 105
Sioux Falls, SD 57105
V. RECEIPT OF ACKNOWLEDGMENT
This notice is effective as of today. This notice will expire seven years after the date which the record was created. By signing below, I acknowledge that I have received a copy of this notice.
Printed Patient Name (or representative)