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.

“Protected Health Information” (PHI) is information about you, including demographic information that may identify you and that relates to your past, present or future physical health condition and related health care services.

 

 

Your Rights

This section explains your rights and how we are required to acknowledge them. With respect to your PHI, you have the following rights:

Request a copy of your paper or electronic PHI:

  • You have the right to inspect and obtain a copy of your PHI in paper or electronic form, if it is readily producible in such form or format. This request must be made in writing. You may not be able to obtain all of your PHI in certain cases, for example, we may deny your request if a treating provider determines something in your file might endanger you or someone else.
  • Upon request, we will supply you with a Request to Inspect or Copy Patient Information form. The form contains the name of our privacy official and his/her contact information.
  • If we approve your request, we will provide a copy or a summary of your PHI, as requested. We may charge a reasonable fee for cost of labor, postage, and supplies associated with your request (in compliance with state and federal laws regarding

medical records request).

Receive a paper copy of this Notice of Privacy Practices:

  • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.

Request correction of your PHI:

  • You have the right to request corrections or amendments to your PHI if you think it is incorrect or incomplete.
  • Upon request, we will supply you with the Request to Amend Patient Record form. All requests for amendment must be in writing and contain a reason to support the request.
  • We may deny your request for an amendment for example, if the request does not include a reason to support the request; our response will be in writing within 60 days.

Request confidential or alternative communication:

  • You can request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by email. We will accommodate all reasonable requests.
  • To request alternative communications, you must make your request in writing using the contact information at the bottom of this notice; a Request for Alternative Communications form will be provided upon request.

Ask us to limit the PHI we disclose:

  • You have the right to request restrictions on our use or disclosure of your PHI to carry out treatment, payment, or healthcare operations. We will consider these requests on a case-by-case basis. We are not required to agree to your request unless your request pertains to a treatment service for which you have paid for out-of-pocket in full, and you ask us not to disclose PHI pertaining solely to that service with your health insurer, for the purpose of payment or our health care operations.
  • You must make your request in writing using the contact information at the bottom of this notice; a Request to Restrict Disclosure to Health Plan form will be provided upon request.

Receive a list of those to whom we’ve disclosed your PHI:

  • You have the right to request an accounting of disclosures of your PHI made by us in the six years prior to the date on which you make the request. We are not required to list certain disclosures, such as disclosures made for treatment, payment, and health care operations purposes (TPO) or disclosures you have asked us to make.
  • You must submit your request in writing using the contact information at the bottom of this notice and a Request for Accounting of Disclosure of PHI form will be provided upon request. The first accounting of disclosures (Response to Request for Disclosure form) you request within any 12-month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting of disclosures.

File a complaint if you believe your privacy rights have been violated:

  • If you believe your privacy rights have been violated, you may file a complaint using the contact information provided at the bottom of this notice; we will supply you with a Complaint Form upon request.
    • All complaints must be submitted in writing.
    • You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights.
    • We will not retaliate against you for filing a complaint.

Your Choices

This section addresses your choices regarding PHI we may use or disclose.

You have the choice to tell us to:

    • Disclose PHI with your family and friends about your condition or care.
    • Disclose your PHI when disaster relief organizations seek your PHI to coordinate your care.
    • Note: If you are unable to communicate your preference, for example if you are unconscious, we may go ahead and disclose your PHI if we believe it is in your best interest and you have not previously indicated otherwise.

We will not use or disclose your PHI in these cases without permission:

    • Marketing purposes. We obtain your written authorization before we use or disclose your PHI for marketing purposes.
    • Sale of your information. We will not sell your PHI to a third party without your written authorization.
    • For uses and disclosures not described in this Notice of Privacy Practices.
    • Note: If you provide us with written permission to use or disclose your PHI, you may later revoke that authorization at any time to stop future uses or disclosures by providing us with notice of your revocation using the contact information provided below. All revocations must be in writing. Your revocation of an authorization may not apply to any uses or disclosures of your PHI already made in reliance on that authorization.

Our Uses and Disclosures

This section lists ways in which we may use and disclose your PHI. We can use and disclose your PHI for the following purposes.

Treatment, payment, and health care operations:

    • Treatment: We may use and disclose your PHI for purposes related to your treatment. For example, we may use and disclose your PHI to plan your care and treatment, including preauthorization and pre-certification, and to communicate with other providers such as referring physicians.
    • Payment: We may use and disclose your PHI to obtain payment for our services. For example, we may use your PHI for billing purposes and coordination of payment for services.
    • Health Care Operations: We may use and disclose your PHI to run our practice, improve your care, and contact you. For example, we may use your PHI to conduct quality and outcome assessments for improvement of care we render, or to share with our contracted third-party business associates for services, such as answering services, transcriptionists, record keeping, consultants, and legal counsel. We may also use and disclose your PHI to communicate to you via newsletters, mailings, or other means regarding treatment options, health related information, disease management programs, wellness programs, or other community based initiatives or activities in which our practice is participating.

Public health and safety issues:

    • We may use and disclose your PHI for certain public health activities, such as handling product recalls or preventing disease.
    • We may also use and disclose your PHI when reporting suspected abuse, neglect or domestic violence in compliance with state and federal laws, or to prevent or reduce a serious threat to health or safety.

Compliance with law and other permissible purposes:

We may use or disclose your PHI as required to comply with law or in connection with legal processes, such as disclosing PHI to:

    • Health oversight agencies for activities authorized by law.
    • Law enforcement officials for law enforcement activities.
    • Address workers’ compensation, law enforcement, and other government requests.
    • Respond to lawsuits and legal actions such as a court order, subpoena, warrant, summons, or similar process if authorized under state or federal law.
    • An executor or administrator of a deceased person’s estate to the extent that person is acting as an authorized personal representative.
    • Organ or tissue procurement organizations for donation purposes or with medical examiners or funeral directors as needed for them to perform their duties.

Our Responsibilities

    • We are required by law to maintain the privacy of your PHI.
    • If you have a personal representative, such as a legal guardian, we will treat that person as if that person is you with respect to disclosures of your PHI.
    • We are required to promptly notify you of any breaches of Unsecured PHI following the discovery of the breach.
    • We are also required to provide you with notice of our legal duties and privacy practices with respect to our PHI, such as this Notice of Privacy Practices and abide by the terms of our most current Notice of Privacy Practices.

Changes to the terms of this notice:

We reserve the right to change our practices contained in this Notice of Privacy Practices and to make the new provisions effective for all your PHI that we maintain. Should our information practices change, we will post the revised Notice of Privacy Practices notice and the revised notice will be available upon request. We will not use or disclose your PHI without your authorization, except as described in our most current Notice of Privacy Practices.

Contact:

If you have any questions about this Notice of Privacy Practices, or if you would like to file a complaint, please contact Dr. Rebecca Sutphin by phone at 919-909-1095 or by emailing info@sutphinchiro.com