HIPAA Privacy Notice

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

Understanding Your Health Record/Information

Each time you visit Back Foundation Chiropractic, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

• Basis for planning your care and treatment.

• Means of communication among the many health professionals who contribute to your care.

• Legal document describing the care you received.

• Means by which you or a third-party payer can verify that services billed were actually provided.

• Tool in educating health professionals.

• Source of data for medical research.

• Source of information for public health officials charged with improving the health of the nation.

• Source of data for facility planning and marketing.

• Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Your Health Information Rights

Although your health record is the physical property of Back Foundation Chiropractic, the information belongs to you.

You have the right to:

• Request a restriction on certain uses and disclosures of your information.

• Obtain a paper copy of this notice of information practices upon request.

• Inspect and obtain a copy of your health record as provided by 45 CFR 164.524.

• Amend your health record as provided by 45 CFR 164.526.

• Obtain an accounting of disclosures of your health information as provided by 45 CFR 164.528.

• Request communications of your health information by alternative means or at alternative locations.

• Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Our Responsibilities

Back Foundation Chiropractic is required to:

• Maintain the privacy of your health information.

Consent to Treatment

• Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.

• Abide by the terms of this notice.

• Notify you if we are unable to agree to a requested restriction.

• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us.

We will not use or disclose your health information without your authorization, except as described in this notice.

Examples of Disclosures for Treatment, Payment, and Health Operations

• We will use your health information for treatment.

• For example: Information obtained by a chiropractor, physical therapist, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you.

• We will use your health information for payment.

• For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may

include information that identifies you, as well as your diagnosis, procedures, and supplies used.

• We will use your health information for regular health operations.

• For example: Members of the chiropractic staff may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Other Disclosures

• Business Associates: There are some services provided in our organization through contracts with business associates. Examples include our accounting and billing services. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do.

• Public Health: We may disclose your health information as required by law to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

• Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Privacy and Sharing of Information

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

I understand and agree that in the event it is necessary to protect my health and safety or in a medical emergency, you are authorized to communicate with the emergency contact I have provided.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact our office at (714) 798-3032.

If you believe your privacy rights have been violated, you can file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services.