Fuller Chiropractic Clinic
Garry T. Fuller, D.C., PC
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Fuller Chiropractic Clinic is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about your medical condition and the care and treatment you receive from Fuller Chiropractic and other health care providers. This Notice details how your PHI may be used and disclosed to third parties for purposes of your care, payment for your care, health care operations of Fuller Chiropractic and for other purposes permitted or required by law. This Notice also details your rights regarding your PHI.
USE OR DISCLOSURE OF PHI
Fuller Chiropractic Clinic may use and/or disclose your PHI for purposes related to your treatment, payment for you care, and health care operations of Fuller Chiropractic Clinic. The following are examples of the types of uses and/or disclosures of your PHI that may occur. These examples are not meant to include all possible types of use and/or disclosure.
Treatment – In order to provide care to you, Fuller Chiropractic Clinic will provide your PHI to those health care professionals directly involved in your treatment so that they may understand your medical condition and needs and provide advice or treatment (e.g., your physician). For example, your physician may need to know how your condition is responding to the treatment provided by Fuller Chiropractic Clinic.
Payment – In order to get paid for some or all of the health care provided by Fuller Chiropractic Clinic, the Practice may provide your PHI, directly or through a billing service, to appropriate third party payors, pursuant to their billing and payment requirements. For example, Fuller Chiropractic may need to provide your health insurance carrier with information about health care services that you received from Fuller Chiropractic Clinic so that Fuller Chiropractic can be properly reimbursed.
Health Care Operations – In order for Fuller Chiropractic Clinic to operate in accordance with applicable law and insurance requirements and in order for Fuller Chiropractic to provide quality and efficient care, it may be necessary for Fuller Chiropractic to compile, use and/or disclose your PHI. For example, Fuller Chiropractic may use your PHI in order to evaluate the performance of Fuller Chiropractic Clinic’s personnel in providing care to you.
AUTHORIZATION NOT REQUIRED
Fuller Chiropractic Clinic may use and/or disclose your PHI, without a written Authorization from you, in the following instances:
De-identified Information – Your PHI is altered so that it does not identify you and, even with your name, cannot be used to identify you.
Business Associate – To a business associate, which is someone who Fuller Chiropractic Clinic contracts with to provide a service necessary for your treatment, payment for your treatment and health care operations (e.g., billing service, or transcription service). Fuller Chiropractic Clinic will obtain satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI.
Personal Representative – To a person who, under applicable law, has the authority to represent you in making decisions related to your health care.
Public Health Activities – Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent or control disease, injury or disability. This includes reports of child abuse or neglect.
Abuse, Neglect or Domestic Violence – To a government authority if Fuller Chiropractic Clinic is required by law to make such disclosure. If Fuller Chiropractic is authorized by law to make such a disclosure, it will do so if it believes that the disclosure is necessary to prevent serious harm or if Fuller Chiropractic believes that you have been the victim of abuse, neglect or domestic violence. Any such disclosure will be made in accordance with the requirements of law, which may also involve notice to you of the disclosure.
Health Oversight Activities – Such activities, which must be required by law, involve government agencies involved in oversight activities that relate to the health care system, government benefit programs, government regulatory programs and civil rights law. Those activities include, for example, criminal investigations, audits, disciplinary actions, or general oversight activities relating to the community’s health care system.
Judicial and Administrative Proceeding – For example, Fuller Chiropractic Clinic may be required to disclose your PHI in response to a court order or a lawfully issued subpoena.
Law Enforcement Purposes – In certain instances, your PHI may have to be disclosed to a law enforcement official for law enforcement purposes. Law enforcement purposes include: (1) complying with a legal process (i.e., subpoena) or as required by law;
(2) information for identification and location purposes (e.g., suspect or missing person); (3) information regarding a person who is or is suspected to be a crime victim; (4) in situations where the death of an individual may have resulted from criminal conduct; (5) in the event of a crime occurring on the premises of Fuller Chiropractic Clinic; and (6) a medical emergency (not on the Practice’s premises) has occurred, and it appears that a crime has occurred.
Coroner or Medical Examiner – Fuller Chiropractic Clinic may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death, or to a funeral director as permitted by law and as necessary to carry out its duties.
Avert a Threat to Health or Safety – Fuller Chiropractic Clinic may disclose your PHI if it believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to an individual who is reasonable able to prevent or lessen the threat.
Emergency Situations - Fuller Chiropractic Clinic may disclose your PHI for the purpose of obtaining or rendering emergency treatment to you provided that the Practice attempts to obtain your Consent as soon as possible; or to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating your care with such entities in an emergency situation.
Workers’ Compensation – If you are involved in a Workers’ Compensation claim, Fuller Chiropractic may be required to disclose your PHI to an individual or entity that is part of the Workers’ Compensation system.
Required by Law – If otherwise required by law, but such use or disclosure will be made in compliance with the law and limited to the requirements of the law.
Uses and/or disclosures, other than those described above, will be made only with your written Authorization, which you may revoke at any time.
Fuller Chiropractic Clinic may, from time to time, contact you to provide appointment reminders. The reminder may be in the form of email or text message. Fuller Chiropractic will try to minimize the amount of information contained in the reminder. Fuller Chiropractic Clinic may also contact you by phone and, if you are not available, Fuller Chiropractic will leave a message for you.
SIGN IN LOG
This office maintains a sign-in log at the reception desk that you are asked to sign before seeing the doctor. Your name may be seen by others who are in the reception area.
Fuller Chiropractic Clinic may, from time to time, contact you about treatment alternatives, or other health benefits or services that may be of interest to you.
You have the right to:
Revoke any Authorization, in writing, at any time. To request a revocation, you must submit a written request to Fuller Chiropractic Clinic’s Privacy Officer.
Request restrictions on certain use and/or disclosure of your PHI as provided by law. However, the Practice is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to Fuller Chiropractic’s Privacy Officer. In your written request, you must inform Fuller Chiropractic Clinic of what information you want to limit whether you want to limit Fuller Chiropractic’s use or disclose, or both, and to whom you want the limits to apply. If Fuller Chiropractic Clinic agrees to your request, the Practice will comply with your request unless the information is needed in order to provide you with emergency treatment.
Receive confidential communications of PHI by alternative means or at alternative locations. You must make your request in writing to Fuller Chiropractic Clinic’s Privacy Officer. Fuller Chiropractic will accommodate all reasonable requests.
Inspect and copy your PHI as provided by law. To obtain a copy of your PHI, you must submit a written request (forms are available from Fuller Chiropractic Clinic) to the Practice’s Privacy Officer. In certain situations that are defined by law, Fuller Chiropractic Clinic may deny your request, but you will have the right to have the denial reviewed. Fuller Chiropractic Clinic reserves the right to charge you a fee for the cost of copying, mailing or other supplies associated with your request.
Amend your PHI as provided by law. To request an amendment, you must submit a written request to Fuller Chiropractic’s Privacy Officer. You must provide a reason that supports your request. Fuller Chiropractic Clinic may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by Fuller Chiropractic Clinic (unless the individual or entity that created the information is no longer available, if the information is not part of your PHI maintained by Fuller Chiropractic Clinic, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with Fuller Chiropractic’s denial, you have the right to submit a written statement of disagreement.
Receive a paper copy of this Privacy Notice from Fuller Chiropractic Clinic upon request.
Complain to Fuller Chiropractic Clinic, or to the Secretary of Health and Human Services, Office of Civil Rights, Hubert H. Humphrey Building, 200 Independence Avenue, S.W., Room 509F HHH Building, Washington, D.C. 20201. Or you may contact a regional office of the Office of Civil Rights, which can be found at www. hhs.gov/ocr/regmail.html. To file a complaint with Fuller Chiropractic Clinic, you contact the Practice’s Privacy Officer. All complaints must be in writing.
FULLER CHIROPRACTIC CLINIC’S REQUIREMENTS
Fuller Chiropractic Clinic:
Is required by law to maintain the privacy of your PHI and to provide you with this Privacy Notice of the Fuller Chiropractic’s legal duties and privacy practices with respect to your PHI.
Is required to abide by the terms of this Privacy Notice.
Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.
Will not retaliate against you for making a complaint.
Will provide you with a paper copy of this Privacy Notice if you so request.
This authorization is prepared pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et. seq. and regulations there under, as amended from time to time (collectively referred to as "HIPAA"). This authorization affects your rights in the privacy of your personal healthcare information.