NOTICE OF PRIVACY PRACTICES<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /> 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUMAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW THE DOCUMENT CAREFULLY. 

Lifestyle Chiropractic is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Disclosure of Your Health Care Information

Treatment

We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment, or healthcare operations. (Example)

“On occasion, it may be necessary to seek consultation regarding your condition from other healthcare providers associated with Lifestyle Chiropractic.” 

“It is our policy to provide a substitute health care provider, authorized by Lifestyle Chiropractic to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary healthcare provider’s absence due to vacation, sickness, or other emergency situation.” 

Payment

 

We may disclose your health information to your insurance provider for the purpose of payment or healthcare operations. (Example) 

“As a courtesy to our patients, we will submit an itemized billing statement to your insurance carrier for the purpose of payment to Lifestyle Chiropractic for healthcare services rendered.  If you pay for your healthcare services personally, we will, as a courtesy, provide an itemized billing to your insurance carrier for the purpose of reimbursement to you.  The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the healthcare services received.”

Workers’ Compensation 

We may disclose your health information as necessary to comply with State Workers’ Compensation Laws. 

Emergencies 

We may disclose you health information to notify or assist in notifying a family member, or another person responsible for your care regarding your medical condition, in the event of an emergency, or of your death. 

Public Health 

As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, and reporting disease or infectious exposure. 

Judicial and Administrative Proceedings 

We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes. 

Research 

We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board. 

Public Safety 

It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public. 

Specialized Government Agencies 

We may disclose your health information for military, national security, prisoner and government benefit purposes. 

Marketing 

We may contact you for marketing and fundraising purposes as described below: (example) 

            “As a courtesy to our patients, it is our policy to call your home at times to remind you of your appointment time or discuss a missed appointment.  If you are not at home, we leave a reminder message on your answering machine or with the person answering the phone.  No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment, along with a  request to call our office if you need to cancel or reschedule your appointment.”

“It is our practice to participate in charitable events to raise awareness, food donations, gifts, money, etc.  During these times, we may send you a letter, postcard, invitation, or call your home to invite you to participate in the charitable activity.  We will provide you with information about the type of activity, the dates and times, and request your participation in such an event. It is not our policy to disclose any personal health information about your condition for the purpose of Lifestyle Chiropractic sponsored fund-raising events.”

“It is also our practice to recognize the REFERRALS of our entrusting patients.  As a token of appreciation, we will likely respond by inserting your first name, followed by your last initial.  If a PATIENT TESTIMONIAL is submitted, you may request to have your last name removed.”

Change of Ownership 

In the event that Lifestyle Chiropractic is sold or merged with another organization, your health information will become property of the new owner. 

Your Health Information Rights 

q       You have the right to request restrictions on certain uses and disclosures of your health information.  Please be advised; however, that Lifestyle Chiropractic is not required to agree to the restriction that you requested. 

q       You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication, upon your request. 

q       You have the right to inspect and copy your health information. 

q       You have the right to request that Lifestyle Chiropractic amend your protected health information.  Please be advised; however, that Lifestyle Chiropractic is not required to agree to amend your protected health information.  If your request to amend your health information is denied, you will be provided with an explanation of our denial reason and information about how you can disagree with the denial. 

q       You have the right to receive an accounting disclosure of your protected health information made by Lifestyle Chiropractic. 

q       You have the right to a paper copy of this Notice of Privacy Practices at any time upon request. 

Changes to this Notice of Privacy Practices 

Lifestyle Chiropractic reserves the right to amend this Notice of Privacy Practices at any time and will make the new provisions effective for all information that it maintains.  Until such amendment is made, Lifestyle Chiropractic is required by law to comply with this Notice. 

Lifestyle Chiropractic is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information.  If you have any questions about any part of this notice or if you need more information about your privacy rights, please contact: Lifestyle Chiropractic by calling 925-362-9200.  You may make an appointment for a personal conference in person or by telephone within 2 working days. 

Complaints 

Complaints about your privacy rights or how Lifestyle Chiropractic has handled your health information should be directed toward the office manager, Dr. Mark Sembrat, D.C. by calling the office at 925-362-9200.  If you are unsatisfied with how this office handles your complaint, you may submit a formal claim to: 

            DHHS, Office of Civil rights 

            <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" />

            Room 509F HHH Building 

            Washington, DC 20201 

This notice is effective April 1, 2004 

I have read the Privacy Notice and understand my rights contained in the notice. 

By way of my signature on the “Patient Confidential Information” form, I provide Lifestyle Chiropractic with my authorization and consent to use and disclose my protected healthcare information for the purposes of treatment, payment, and healthcare operations as described in the Privacy Notice.