Notice of Privacy Practices For:
Ottawa Chiropractic, P.L.L.C
184 James St.
Holland, MI 49424
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.
If
you have any questions about this Notice please contact our Privacy Contact or
any staff member in our office.
Our
Privacy Contact is Julie Heerspink.
This
Notice of Privacy Practices describes how we may use and disclose your protected
health information to carry out your treatment, collect payment for your care
and manage the operations of this clinic. It also describes our policies concerning the use and
disclosure of this information for other purposes that are permitted or required
by law. It also describes your
rights to access and control your protected health information. “Protected health information” is information about you,
including demographic information that may identify you, that relates to your
past, present or future physical or mental health or condition and related
health care services.
We
are required by federal law to abide by the terms of this Notice of Privacy
Practices. We may change the terms
of our notice, at any time. The new
notice will be effective for all protected health information that we maintain
at that time. You may obtain
revisions to our Notice of Privacy Practices here or by calling the office and
requesting that a revised copy be sent to you in the mail or asking for one at
the time of your next appointment.
1. Uses and Disclosures of Protected Health Information
Uses
and Disclosures of Protected Health Information Based Upon Your Implied Consent
By
applying to be treated in our office, you are implying consent to the use and
disclosure of your protected health information by your physician, our office
staff and others outside of our office that are involved in your care and
treatment for the purpose of providing health care services to you.
Your protected health information may also be used and disclosed to bill
for your health care and to support the operation of the physician’s practice.
Following
are examples of the types of uses and disclosures of your protected health care
information we will make, based on this implied consent.
These examples are not meant to be exhaustive but to describe the types
of uses and disclosures that may be made by our office.
Treatment: We will use and disclose your protected health information to
provide, coordinate, or manage your health care and any related services.
This includes the coordination or management of your health care with a
third party that has already obtained your permission to have access to your
protected health information. For
example, we would disclose your protected health information, as necessary, to
another physician who may be treating you.
Your protected health information may be provided to a physician to whom
you have been referred to ensure that the physician has the necessary
information to diagnose or treat you.
In addition, we may disclose your protected health
information from time-to-time to another physician or health care provider
(e.g., a specialist or laboratory) who, at the request of your physician,
becomes involved in your care by providing assistance with your health care
diagnosis or treatment to your physician.
Payment: Your protected health information will be used, as needed, to
obtain payment for your health care services.
This may include certain activities that your health insurance plan may
undertake before it approves or pays for the health care services we recommend
for you such as; making a determination of eligibility or coverage for insurance
benefits, reviewing services provided to you for medical necessity, and
undertaking utilization review activities.
For example, obtaining approval for chiropractic spinal adjustments may
require that your relevant protected health information be disclosed to the
health plan to obtain approval for those services.
Healthcare Operations: We may use or disclose, as needed, your protected health
information in order to support the business activities of your physician’s
practice. These activities include,
but are not limited to, quality assessment activities, employee review
activities and training of chiropractic students.
For
example, we may disclose your protected health information to chiropractic
interns or precepts that see patients at our office. In addition, we may use a sign-in sheet at the registration
desk where you will be asked to sign your name and indicate your physician.
Communications between you and the doctor or his assistants may be
recorded to assist us in accurately capturing your responses.
We may also call you by name in the waiting room when your physician is
ready to see you. We may use or
disclose your protected health information, as necessary, to contact you to
remind you of your appointment.
We
will share your protected health information with third party “business
associates” that perform various activities (e.g., billing, transcription
services) for the practice. Whenever
an arrangement between our office and a business associate involves the use or
disclosure of your protected health information, we will have a written contract
with that business associate that contains terms that will protect the privacy
of your protected health information.
We
may use or disclose your protected health information, as necessary, to provide
you with information about treatment alternatives or other health-related
benefits and services that may be of interest to you. We may also use and disclose your protected health
information for other marketing activities.
For example, your name and address may be used to send you a newsletter
about our practice and the services we offer.
We may also send you information about products or services that we
believe may be beneficial to you. You
may contact our Privacy Contact to request that these materials not be sent to
you.
Uses and Disclosures of Protected Health Information That
May Be Made With Your Written Authorization
Other
uses and disclosures of your protected health information will be made only
with your written authorization, unless otherwise permitted or required by law
as described below.
For
Example, with your written, signed authorization, we may use your demographic
information and the dates that you received treatment from your physician, as
necessary, in order to contact you for fundraising activities supported by our
office. With your written, signed
authorization, we may use your photograph on a “Birthday Board” or other
display in our waiting room or your testimonial story in a folder kept in the
waiting room for patient education purposes.
You
may revoke any of these authorizations, at any time, in writing, except to the
extent that your physician or the physician’s practice has taken an action in
reliance on the use or disclosure indicated in the authorization.
Other
Permitted and Required Uses and Disclosures That May Be Made With Your
Authorization or Opportunity to Object
In
the following instance where we may use and disclose your protected health
information, you have the opportunity to agree or object to the use or
disclosure of all or part of your protected health information.
If you are not present or able to agree or object to the use or
disclosure of the protected health information, then your physician may, using
professional judgment, determine whether the disclosure is in your best
interest. In this case, only the
protected health information that is relevant to your health care will be
disclosed.
Others Involved in Your Healthcare:
Unless you object, we may disclose to a member of your family, a relative, a
close friend or any other person you identify, your protected health information
that directly relates to that person’s involvement in your health care.
If you are unable to agree or object to such a disclosure, we may
disclose such information as necessary if we determine that it is in your best
interest based on our professional judgment.
We may use or disclose protected health information to notify or assist
in notifying a family member, personal representative or any other person that
is responsible for your care of your location, general condition or death.
Finally, we may use or disclose your protected health information to an
authorized public or private entity to assist in disaster relief efforts and to
coordinate uses and disclosures to family or other individuals involved in your
health care.
Other
Permitted and Required Uses and Disclosures That May Be Made Without Your
Consent, Authorization or Opportunity to Object
We
may use or disclose your protected health information in the following
situations without your consent or authorization. These situations include:
Required By Law: We may use or disclose your protected health information to the
extent that the use or disclosure is required by law. The use or disclosure will
be made in compliance with the law and will be limited to the relevant
requirements of the law. You will be notified, as required by law, of any such
uses or disclosures.
Public Health: We may disclose your protected health information for public
health activities and purposes to a public health authority that is permitted by
law to collect or receive the information. The disclosure will be made for the
purpose of controlling disease, injury or disability. We may also disclose your
protected health information, if directed by the public health authority, to a
foreign government agency that is collaborating with the public health
authority.
Communicable Diseases: We may disclose your protected health information, if
authorized by law, to a person who may have been exposed to a communicable
disease or may otherwise be at risk of contracting or spreading the disease or
condition.
Health Oversight: We may disclose protected health information to a health oversight
agency for activities authorized by law, such as audits, investigations, and
inspections. Oversight agencies seeking this information include government
agencies that oversee the health care system, government benefit programs, other
government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected health information to a public
health authority that is authorized by law to receive reports of child abuse or
neglect. In addition, we may disclose your protected health information if we
believe that you have been a victim of abuse, neglect or domestic violence to
the governmental entity or agency authorized to receive such information. In
this case, the disclosure will be made consistent with the requirements of
applicable federal and state laws.
Food and Drug Administration:
We may disclose your protected health information to a person or company
required by the Food and Drug Administration to report adverse events, product
defects or problems, biologic product deviations, track products; to enable
product recalls; to make repairs or replacements, or to conduct post marketing
surveillance, as required.
Legal Proceedings: We may disclose protected health information in the course of any
judicial or administrative proceeding, in response to an order of a court or
administrative tribunal (to the extent such disclosure is expressly authorized),
in certain conditions in response to a subpoena, discovery request or other
lawful process.
Law Enforcement: We may also disclose protected health information, so long as
applicable legal requirements are met, for law enforcement purposes.
These law enforcement purposes include (1) legal processes and otherwise
required by law, (2) limited information requests for identification and
location purposes, (3) pertaining to victims of a crime, (4) suspicion that
death has occurred as a result of criminal conduct, (5) in the event that a
crime occurs on the premises of the practice, and (6) medical emergency (not on
the Practice’s premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation:
We may disclose protected health information to a coroner or medical examiner
for identification purposes, determining cause of death or for the coroner or
medical examiner to perform other duties authorized by law.
We may also disclose protected health information to a funeral director,
as authorized by law, in order to permit the funeral director to carry out their
duties. We may disclose such
information in reasonable anticipation of death. Protected health information
may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
Research: We may disclose your protected health information to researchers
when an institutional review board has approved their research and that review
board has reviewed the research proposal and established protocols to ensure the
privacy of your protected health information.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose
your protected health information, if we believe that the use or disclosure is
necessary to prevent or lessen a serious and imminent threat to the health or
safety of a person or the public. We may also disclose protected health
information if it is necessary for law enforcement authorities to identify or
apprehend an individual.
Military Activity and National Security:
When the appropriate conditions apply, we may use or disclose protected health
information of individuals who are Armed Forces personnel (1) for activities
deemed necessary by appropriate military command authorities; (2) for the
purpose of a determination by the Department of Veterans Affairs of your
eligibility for benefits, or (3) to foreign military authority if you are a
member of that foreign military services. We may also disclose your protected
health information to authorized federal officials for conducting national
security and intelligence activities, including for the provision of protective
services to the President or others legally authorized.
Workers’ Compensation: We may disclose your protected health information, as
authorized, to comply with workers’ compensation laws and other similar
legally-established programs.
Inmates: We may use or disclose your protected health information if you
are an inmate of a correctional facility and your physician created or received
your protected health information in the course of providing care to you.
Required Uses and Disclosures:
Under the law, we must make disclosures to you and when required by the
Secretary of the Department of Health and Human Services to investigate or
determine our compliance with the requirements of Section 164.500 et. seq.
2. Your Rights
Following
is a statement of your rights with respect to your protected health information
and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health
information.
This means you may inspect and obtain a copy of protected health
information about you that is contained in a designated record set for as long
as we maintain the protected health information.
A “designated record set” contains medical and billing records and
any other records that your physician and the practice uses for making decisions
about you.
Under
federal law, however, you may not inspect or copy the following records;
psychotherapy notes; information compiled in reasonable anticipation of, or use
in, a civil, criminal, or administrative action or proceeding, and protected
health information that is subject to law that prohibits access to protected
health information. Depending on
the circumstances, a decision to deny access may be reviewable.
In some circumstances, you may have a right to have this decision
reviewed. Please contact our
Privacy Contact if you have questions about access to your medical record.
You have the right to request a restriction of your protected
health information.
This means you may ask us not to use or disclose any part of your
protected health information for the purposes of treatment, payment or
healthcare operations. You may also
request that any part of your protected health information not be disclosed to
family members or friends who may be involved in your care or for notification
purposes as described in this Notice of Privacy Practices.
Your request must be in writing and state the specific restriction
requested and to whom you want the restriction to apply.
Your
physician is not required to agree to a restriction that you may request.
If physician believes it is in your best interest to permit use and
disclosure of your protected health information, your protected health
information will not be restricted. If
your physician does agree to the requested restriction, we may not use or
disclose your protected health information in violation of that restriction
unless it is needed to provide emergency treatment.
With this in mind, please discuss any restriction you wish to request
with your physician. You may
request a restriction by presenting your
request, in writing to the staff member identified as “Privacy Contact” at
the top of this form. A simple
sentence, “Do not use my PHI (Protected Health Information) for education of
Chiropractic Students.” or “Do not send any communications to my home
address.” Sign and date your request.
Ask that the staff provide you with a photocopy of your request initialed
by them. This copy will serve as
your receipt.
You have the right to request to receive confidential
communications from us by alternative means or at an alternative location.
We will accommodate reasonable requests. We may also condition this accommodation by asking you for
information as to how payment will be handled or specification of an alternative
address or other method of contact. We will not request an explanation from you as to the basis
for the request. Please make this request in writing to our Privacy Contact.
You may have the right to have your physician amend your protected
health information.
This means you may request an amendment of protected health information
about you in a designated record set for as long as we maintain this
information. In certain cases, we
may deny your request for an amendment. If
we deny your request for amendment, you have the right to file a statement of
disagreement with us and we may prepare a rebuttal to your statement and will
provide you with a copy of any such rebuttal.
Please contact our Privacy Contact to determine if you have questions
about amending your medical record.
You have the right to receive an accounting of certain disclosures
we have made, if any, of your protected health information.
This right applies to disclosures for purposes other than treatment,
payment or healthcare operations as described in this Notice of Privacy
Practices. It excludes disclosures
we may have made to you, for a facility directory, to family members or friends
involved in your care, pursuant to a duly executed authorization or for
notification purposes. You have the
right to receive specific information regarding these disclosures that occurred
after April 14, 2003. You may
request a shorter timeframe. The right to receive this information is subject to
certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of this notice from us,
upon request, even if you have agreed to accept this notice electronically.
3.
Complaints
You
may complain to us or to the Secretary of Health and Human Services if you
believe your privacy rights have been violated by us. You may file a complaint
with us by notifying our privacy contact of your complaint. We will not
retaliate against you for filing a complaint.
Our Privacy Contact is Dr. Eric R Hartman.
You may contact our Privacy Contact, or any staff member, including your
physician at (616)399-3563 for further information about the complaint
process.
This
notice was published and becomes effective on April 10, 2003
