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 Cummings Chiropractic Office, P.C. (CCO) might have to use or disclose your Protected Health Information (PHI). This information listed in numbers 1 - 3 below may be used or released without your consent:
- Your chiropractor or a staff member may disclose your Health Information including 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.
- Our staff may disclose your examination and treatment records as well as billing records to another party (such as an insurance carrier, an HMO, a PPO, or your employer) only when they may be responsible for the payment of your services.
- Your chiropractor and staff may find it necessary 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.
- Your chiropractor and staff may use your name, address(es), phone number(s), 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. 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 you or the methods we use to obtain reimbursement for your care.
You may inspect a copy of 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 office is open.
Our Privacy Pledge
We have and always will respect your privacy. 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:
- 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.
- We are permitted to use or disclose your Health Information if we are providing health care services to you as an inmate.
- We are permitted to use or disclose your Health Information if we are providing health care services to you in an emergency.
- 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.
- 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 federal or state laws may also require us to use or disclose your Health Information without your consent or authorization:
- Food and Drug Administration (FDA): We may disclose to the FDA Health Information relative to adverse events with respect to supplements, product or product defects to enable product recalls, repairs or replacement.
- Workers Compensation: We may disclose Health Information to the extent authorized by and to the extent necessary to comply with laws relating to Workers Compensation or other similar programs established by law. This currently includes reports to your employer.
- Public Health: As required by law, we may disclose your Health Information to public health or legal authorities charged with preventing or controlling disease, injury or disability.
- Abuse, Neglect & Domestic Violence: We may disclose your Health Information to public authorities as allowed by law to report abuse, neglect, or domestic violence.
- Law Enforcement: We may disclose Health Information for law enforcement purposes as required by law or in response to a valid subpoena. Federal law makes provision for your Health Information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
- Health Oversight: We may disclose your Health Information to health care oversight agencies or for health oversight activities.
- Judicial/Administrative Proceedings: We may disclose your Health Information in the course of any judicial or administrative proceeding as allowed or required by law or as directed by a proper court order or in response to a subpoena, discovery request or other lawful process if certain specific requirements are met.
- For Special Governmental Functions: We may disclose your Health Information for specialized governmental functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.
- Communication with Family/Friends: Health professionals,using their best judgment, may disclose without prior authorization to a family member, other relative, close personal friend or any other person deemed responsible, certain Health Information relevant to that person's immediate involvement in your care or payment related to your care. This would apply in situations of such severity that normal consent procedures could not reasonably be followed (for example, acute and debilitating pain, or natural/chemical mental impairment).
- Other Uses: Other uses and disclosures of your Health Information besides those identified in this NOTICE will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as stated below.
Other than the circumstances described above, 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:
- If we have already released your Health Information before we receive your request to revoke your authorization.
- 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 send your request in writing to:
Cummings Chiropractic Office
P.O. Box 890
Yuma, AZ 85366
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 your Health Information released, please specify, in writing, those individuals or organizations. We are not required to agree to your restrictions. How- ever, if we agree with your restrictions, they will be binding. In the event we do not agree to your restrictions, you may either choose to drop your request or seek care from another health care provider.
Your right to receive confidential communication regarding your Health Information
We normally provide information about your Health Information to you in person at the time you receive chiropractic services from us. You may have invited someone to be in the treatment room with you. Their presence gives us implied consent to both provide treatment and discuss your Health Information in front of them. If you do not wish another party to be exposed to this information, ask them to wait for you outside of the treatment room. There may be times we will mail information regarding your health or 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 services that we provide at a place other than your home or, if you would like the information in a different form, please notify us 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 in our files. Requests regarding inspection and/or copying of your Health Information must be in writing. The re- cords must remain in this office, and the copying must be done by CCO staff. A fee will be charged for the staff time and supplies necessary to comply with your request. Rarely will we be able to provide copies at the time of your request.
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, including a reason to support the proposed change. The original information cannot nor will not be eradicated. If we do not agree to your amendment, you may request your “Written Statement of Disagreement” be make a part of your record and have it attached to any future disclosures of your Health Information Record.
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 our services, or to run our practice;
- those disclosures made to you, family, relatives, close friends or other caregivers during the course of providing your care;
- 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 (4-14-03).
We will provide the first accounting of disclosures within any 12 month period without charge. The request must be in writing. 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.
We are required by law to maintain the privacy of your Health Information. We are also required to provide you with 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 when you come in for treatment. If we make a change in our privacy terms the change will apply to all 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. Superbills are given at the time of payment in this office and act as both a receipt as well as an insurance-ready form for patient submission to their insurance company. It contains private Health Information. After this is given to a patient, control and security of this document and its information becomes the patients responsibility.
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. We cannot and will not take any action against you if you file a complaint. While you may make an oral com- plaint at any time, written comments should be addressed to:
Cummings Chiropractic Office
P.O. Box 890
Yuma, AZ 85366
If you would like further information about our privacy policies and practices, please contact us at the above address, in person or by phone. Our phone number is (928) 782-4339.
Call us today (928) 782-4339
- Cummings Chiropractic Office, P.C.
281 W. 24th Street - Suite #140
Yuma, AZ 85364
- (928) 782-4339