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of Privacy Practices for Protected Health Information
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:
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.
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:
wish to revoke your authorization please write to us at:
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.
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.
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.
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:
To contact us If you would like further information about our privacy policies and practices please contact:
This notice is effective as of June 2003.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.
Copyright © 2002 Pennsylvania Chiropractic Association. All rights reserved.
firstname.lastname@example.org © 2015 Barry Wahner and Melinda Zipin Consulting. All rights reserved.