Health Privacy Policy – Wahner Chiropractic

Notice of Privacy Practices for Protected Health Information
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 our 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. 164.520 (b)(1)(iii) (A). 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.

Our Privacy Pledge

We have and always will respect your privacy. Other than the uses and disclosures
we described above, we will not sell or provide any of your health
information to any outside marketing organization. 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 if we are
providing health care services to you based on the orders of another
health care provider.
2)      We are permitted to use or disclose your health information if we provide
healthcare services to you as an inmate.
3)      We are permitted to use or disclose your health information if we provide
healthcare services to you in an emergency.
4)      We are permitted to use or disclose your health information if we are
required by law to treat you and we are unable to obtain your consent
after attempting to do so.
5)      We are permitted to use or disclose your health information if there
are substantial barriers to communicating with you, but in our professional
judgment we believe that you intend for us to provide care. Other
than the circumstances described in the preceding five 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.164.508(b)(5)(i)
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.

If you wish to revoke your authorization please write to us at:
Dr. Barry Wahner
4931 Wissahickon Avenue
Philadelphia, PA 19144

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 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 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 for 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 addressed to:
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore MD 21244-1850

To contact us If you would like further information about our privacy
policies and practices please contact:

Dr. Barry Wahner
4931 Wissahickon Avenue
Philadelphia, PA 19144

This notice is effective as of June 2017.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:
Patient Signature:
Date:
Authorized Provider Representative:
Personal representative printed:
Personal representative signature:
Description of personal representative’s authority to act for the patient: