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.
Life Chiropractic College West is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about your health condition and the care and treatment you receive from the Health Center. The creation of a record detailing the care and services you receive helps this office to provide you with quality health care. This Notice details how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI. The privacy of PHI in patient files will be protected when the files are taken to and from the Health Center by placing the files in a box or brief case and kept within the custody of a doctor or employee of the Health Center authorized to remove the files from the Health Center’s office.
NO CONSENT REQUIRED
The Health Center may use and/or disclose your PHI for the purposes of:
- Treatment – In order to provide you with the health care you require, the Health Center will provide your PHI to those health care professionals, whether on the Health Center’s staff or not, directly involved in your care so that they may understand your health condition and needs.
- Your PHI will be reviewed by members of the College’s faculty who are involved in the administration of patient care.
- Payment – In order to get paid for services provided to you, the Health Center will provide your PHI, directly or through a billing service, to appropriate third party payers, pursuant to their billing and payment requirements.
- Health Care Operations – In order for the Health Center to operate in accordance with applicable law and insurance requirements and in order for the Health Center to continue to provide quality and efficient care, it may be necessary for the Health Center to compile, use and/or disclose your PHI.
The Health Center may use and/or disclose your PHI, without a written Consent from you, in the following additional instances:
- De-identified Information – Information that does not identify you and, even without your name, cannot be used to identify you.
- Business Associate – To a business associate if the Health Center obtains satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI. A business associate is an entity that assists the Health Center in undertaking some essential function, such as a billing company that assists the office in submitting claims for payment to insurance companies or other payers.
- Personal Representative – To a person who, under applicable law, has the authority to represent you in making decisions related to your health care.
- Emergency Situations –
- (i) for the purpose of obtaining or rendering emergency treatment to you provided that the Health Center attempts to obtain your Consent as soon as possible; or
- (ii) 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.
- Your health care provider or a staff member may disclose your health information to contact you to provide appointment reminders. If you are not at home to receive an appointment reminder, a message will be left on your answering machine, voice mail, or with the person who answers the call.
- You have the right to refuse us authorization to contact you to provide appointment reminders. If you refuse us authorization, it will not affect the treatment we provide to you.
This Health Center maintains a sign-in log for individuals seeking care and treatment in the office. This sign-in sheet are located in a position where staff can readily see who is seeking care in the office, as well as the individual’s location within the Health Center’s office suite. This information may be seen by, and is accessible to, others who are seeking care or services in the Health Center’s offices.
The Health Center may disclose to your family member, other relative, a close personal friend, or any other person identified by you, your PHI directly relevant to such person’s involvement with your care or the payment for your care unless you direct the Health Center to the contrary. The Health Center may also use or disclose your PHI to notify or assist in the notification (including identifying or locating) a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. However, in both cases, the following conditions will apply:
- (a) If you are present at or prior to the use or disclosure of your PHI, the Health Center may use or disclose your PHI if you agree, or if the Health Center can reasonably infer from the circumstances, based on the exercise of its professional judgment that you do not object to the use or disclosure.
- (b) If you are not present, the Health Center will, in the exercise of professional judgment, determine whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is directly relevant to the person’s involvement with your care.
Uses and/or disclosures, other than those described above, will be made only 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.
You may request restrictions on certain use and/or disclosure of your PHI as provided by law. However, the Health Center is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to the Health Center’s Privacy Officer. In your written request, you must inform the Health Center of what information you want to limit, whether you want to limit the Health Center’s use or disclosure, or both, and to whom you want the limits to apply. If the Health Center agrees to your request, the Health Center will comply with your request unless the information is needed in order to provide you with emergency treatment.
You Have a Right to
Inspect and obtain a copy your PHI as provided by 45 CFR 164.524. To inspect and copy your PHI, you are requested to submit a written request to the Health Center’s Privacy Officer. The Health Center can charge you a fee for the cost of copying, mailing or other supplies associated with your request.
Receive confidential communications or PHI by alternative means or at alternative locations. You must make your request in writing to the Health Center’s Privacy Officer. The Health Center will accommodate all reasonable requests.
Prohibit report of any test, examination or treatment to your health plan or anyone else for which you pay in cash or by credit card.
Receive an accounting of disclosures of your PHI as provided by 45 CFR 164.528. The request should indicate in what form you want the list (such as a paper or electronic copy).
Receive a paper copy of this Privacy Notice from the Health Center upon request to the Health Center’s Privacy Officer.
Request copies of your PHI in electronic format if this office maintains your records in that format.
Amend your PHI as provided by 45 CFR 164.528. To request an amendment, you must submit a written request to the Health Center’s Privacy Officer. You must provide a reason that supports your request. The Health Center 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 the Health Center (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by the Health Center, 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 the Health Center’s denial, you will have the right to submit a written statement of disagreement.
Receive notice of any breach of confidentiality of your PHI by the Health Center.
Complain to the Health Center or to the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201, 202 619-0257, email: email@example.com if you believe your privacy rights have been violated. To file a complaint with the Health Center, you must contact the Health Center’s Privacy Officer, Dr. Rhina Patania, Life Chiropractic College West Health Center, 25001 Industrial Blvd., Hayward, CA 94545, (510) 780-4567. All complaints must be in writing.
I acknowledge that I was provided a copy of the Notice of Privacy Health Centers and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Health Centers. I understand that this form will be placed in my patient chart and maintained for six years.
HEALTH CENTER REQUIREMNTS
The Health Center:
- Is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Health Center’s legal duties and privacy Health Centers 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 your entire PHI that it maintains.
- Will distribute any revised Privacy Notice to you prior to implementation.
- Will not retaliate against you for filing a complaint.