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Privacy
Policies
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Consents
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Authorizations
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:
1) 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.
2) 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.
3) 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.
4) 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:
1) 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.
2) 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.
3) 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.
4) 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.
5) 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.
6) 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.
7) 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.
8) 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.
9) We are permitted to use or disclose your health
information if we provide health care services to you in an
emergency.
10) 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:
1) If we have already released your health information
before we receive your request to revoke your authorization.
2) 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:
Yeomans-Edinger Chiropractic Center
,
S.C.
404 Eureka Street
P.O. Box
263
Ripon
,
WI
54971
920-748-3644
This notice is
effective as of
April 1, 2003
. This notice will
expire seven years after the date upon which the record was created.
By signing below, I acknowledge that I have received a copy of this
notice.
_____________________________
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 a copy of our privacy notice, 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
Date
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 . 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
WISCONSIN
CHIROPRACTIC ASSOCIATION AUTHORIZATION
Your chiropractor and members of the practice
staff may need to disclose your name, address, phone number, billing
information and your clinical records to the Wisconsin Chiropractic
Association (WCA). This
disclosure will be made if we need the WCA’s assistance to receive
reimbursement for your services or, we need the WCA’s assistance
because the party responsible for reimbursing your services has
improperly processed your claim.
By signing this form you are giving us
authorization to send the WCA this information. You are also giving
the WCA authorization to re-disclose your information to the party
responsible for the payment of your services, the WCA’s legal
counsel, and state or federal agencies that may be asked to
intercede on your behalf.
You may restrict the individuals or
organizations to whom your health care information is released or
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 received your request to revoke
your authorization.
Information that we use or disclose based on
the authorization you are giving us may be subject to re-disclosure
by the person who receives the 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 may send to the WCA at any time. (§164.524).
This notice is effective as of
_______________. 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.
Copyright
© 2001 Wisconsin Chiropractic Association. All rights reserved
Marketing
Authorization
From time to time
our practice would like to make you aware of products or services
that you may have an interest in purchasing. This marketing could be
done by our internal staff or by an outside marketing organization.
Your chiropractor and members of the practice staff may need to use
your health information including your name, address, phone number,
and your clinical records for the purpose of marketing products and
services from
Yeomans-Edinger Chiropractic Center
,
S.C.
to you. We are specifically requesting authorization to market the
following products and/or services to you: Our office from time to time will call or send a postcard
to patients that have not been seen for 3-6 months to check on their health status and remind them of the
importance of chiropractic care. We
acknowledge birthdays through sending birthday cards which may offer
complimentary or discounted products and services. From time to time an office newsletter may be mailed or
emailed to our patients which may include health information, new
services and products, or offer complimentary or discounted products
and services. Patients
my be thanked by postcard, letter, phone call , or listed on a
bulletin board for
referring patients to our office which may include an offer for
complimentary or discounted products and services. We scan the local news media for positive stories about
patients and feature these stories in newsletters
and/or office hangings, pictures etc.. This office may participate
in charitable activities in which exchange for donation of money or
other items may receive free or reduced price off services or
products.
You
may restrict the individuals or organizations to which your health
care information is released or 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. 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 the organization/s listed above
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 permission, 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 for
marketing purposes at any time. Our
practice and staff will receive direct or indirect remuneration from
our marketing activities.
This notice is
effective as of
April 14, 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.
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