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 that are distinct from our health-related service offerings or unrelated to your treatment, that involve more than a promotional gift of nominal value and that are not communicated face-to-face with you. Communications that concern health-related services or your treatment, or that involve promotional gifts of nominal value or face-to-face communications do not require a prior authorization from you.  Marketing may be done by our internal staff or by an outside marketing organization[i]. 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, email 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 may receive a bimonthly “To Your Health” or a more frequent “Health Update” email  newsletter which helps to educate our patients and community about the many benefits of chiropractic. Patients may be thanked by postcard, letter, email, 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.

• No remuneration from a third-party is involved.
• 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.

Marketing Authorization

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 and that I have signed a separate Authorization for Release of Protected Health Information Form.

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.

[1] Our practice will provide you with a separate authorization form if we intend to sell your health information to the outside marketing firm or allow the outside marketing firm use your health information for its own purposes.