Brook West Chiropractic Clinic
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Our practice is dedicated, and we are required by applicable federal and
state laws, to maintain the privacy of your health information. These
laws also require us to provide you with this Notice of our privacy practices,
and to inform you of your rights, and our obligations, concerning your health
information. We are required to follow the privacy practices described
below while this Notice is in effect. This Notice is effective as of
April 1st, 2003, and will remain in effect until we replace it.
CHANGES TO NOTICE:
We reserve the right to change this Notice and the privacy practices described
below at any time in accordance with applicable law. Prior to making
significant changes to our privacy practices, we will alter this Notice to
reflect the changes, and make the revised Notice available to you on request.
Any changes we make to our privacy practices and/or this Notice may be applicable
to health information created or received by us prior to the date of the
changes.
You may request a copy of our Notice at any time. For more information
about our privacy practices, or for additional copies of this Notice, please
contact us using the information listed at the end of this Notice.
PERMITTED USES AND DISCLOSURES OF HEALTH INFORMATION:
A. TREATMENT, PAYMENT, HEALTH CARE OPERATIONS: You should be aware
that during the course of our relationship with you we will likely use and
disclose health information about you for treatment, payment, and healthcare
operations. Examples of these activities are as follows:
Treatment: We may use or disclose your health information to a physician
or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information
in connection with our healthcare operations. Healthcare operations
include quality assessment and improvement activities, reviewing the competence
or qualifications of healthcare professionals, evaluating practitioner and
provider performance, and other business operations.
B. AUTHORIZATIONS: You may specifically authorize us to use your
health information for any purpose or to disclose your health information
to anyone, by submitting such an authorization in writing. Upon receiving
an authorization from you in writing we may use or disclose your health information
in accordance with that authorization. You may revoke an authorization
at any time by notifying us in writing. Your revocation will not affect
any use or disclosures permitted by your authorization while it was in effect.
Unless you give us a written authorization, we cannot use or disclose your
health information for any reason except those permitted by this Notice.
C. DISCLOSURES TO FAMILY AND PERSONAL REPRESENTATIVES: We must
disclose your health information to you, as described in the Patient Rights
section of this Notice. Such disclosures will be made to any of your
personal representatives appropriately authorized to have access and control
of your health information. We may disclose your health information
to a family member, friend or other person to the extent necessary to help
with your healthcare or with payment for your healthcare only if authorized
to do so. In the event of your incapacity or in emergency circumstances,
we will disclose health information based on a determination using our professional
judgment disclosing only health information that is directly relevant to
the person's involvement in your healthcare.
D. MARKETING: We will not use your health information for marketing
communications without your written authorization.
E. USES OR DISCLOSURES REQUIRED BY LAW: We may use or disclose
your health information when we are required to do so by law, including for
public health reasons (e.g., disease reporting). In some instances, and in
accordance with applicable law, we may be required to disclose your health
information to appropriate authorities if we reasonably believe that you
are a possible victim of abuse, neglect, or domestic violence or the possible
victim of other crimes.
F. PATIENT AND THIRD PARTY PROTECTION: Only as permitted by law,
we may disclose your health information to the extent necessary to avert
a serious threat to your health or safety or the health or safety of others.
G. LAW ENFORCEMENT/NATIONAL SECURITY: Under certain circumstances we
may disclose health information relating to members of the Armed Forces to
military authorities. Under certain circumstances we may also disclose
health information relating to inmates or patients to correctional institutions
or law enforcement personnel having lawful custody of those individuals.
We may disclose health information in response to judicial proceedings and
law enforcement inquiries as permitted by law and to authorized federal officials
health information required for lawful intelligence, counterintelligence,
and other national security activities.
H. APPOINTMENT REMINDERS: We may use or disclose your health
information to provide you with appointment reminders (such as voicemail
messages, postcards, or letters).
PATIENT RIGHTS:
A. ACCESS TO RECORDS: Upon submission of a written request to us, you
have the right to review or receive copies of your health information, with
limited exceptions. You may obtain a form to request access by using
the contact information listed at the end of this Notice. You may request
that we provide copies in a format other than photocopies and we will use
the format you request if it is readily available. We will charge you
a reasonable cost-based fee relating to the production of such copies.
If you request copies, we will charge you $0.75 for each page, a fee of no
more than $10 for the labor of copying the records, and postage if you want
the copies mailed to you. (Note: We will not charge you any fees for
retrieving or handling the information or for processing the request.)
The per page dollar amount does not apply to copies of x-rays, for which
we will not charge you more than the actual cost of reproducing the x-rays.
If you request an alternative format, we will charge a reasonable cost-based
fee for providing your health information in that format. If you prefer,
we will prepare a summary or an explanation of your health information for
a fee. Contact us using the information listed at the end of this Notice
if you are interested in receiving a summary of your information instead
of copies. If you request copies in connection with your application
for social security benefits, we will not charge you any fee.
B. ACCOUNTING OF CERTAIN DISCLOSURES. Upon written request, you
have the right to receive a list of instances in which we or our business
associates disclosed your health information for purposes, other than treatment,
payment, healthcare operations and other activities authorized by you, for
the last 6 years, but not before April 14, 2003. If you request this
accounting more than once in a 12-month period, we may charge you a reasonable,
cost-based fee for responding to these additional requests.
C. RESTRICTIONS AND ALTERNATIVE COMMUNICATIONS: You have the
right to request that we place additional restrictions on our use or disclosure
of your health information for treatment, payment and healthcare operations
purposes. Depending on the circumstances of your request we may, or
may not agree to those restrictions. If we do agree to your requested
restrictions we must abide by those restrictions, except in emergency treatment
scenarios. You have the right to request that we communicate with you about
your health information by alternative means or to alternative locations
(e.g., at your place of business rather than at your home). Such requests
must be made in writing, must specify the alternative means or location,
and must provide satisfactory explanation how payments will be handled under
the alternative means or location you request.
D. AMENDMENTS TO RECORDS: You have the right to request that
we amend your health information. Such requests must be made in writing,
and must explain why the information should be amended. We may deny
your request under certain circumstances.
E. ELECTRONIC NOTICES. If you receive this Notice on our Web
site or by electronic mail (e-mail), you are entitled to receive this Notice
in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you
disagree with a decision we made or any decisions we may make regarding the
use, disclosure, or access to your health information you may complain to
us using the contact information listed below. You also may submit
a written complaint to the U.S. Department of Health and Human Services.
We will provide you with the address to file such a complaint upon request.
We support your right to the privacy of your health information. We
will not retaliate in any way if you choose to file a complaint with us or
with the U.S. Department of Health and Human Services.
Please direct any of your questions or complaints to:
Contact: Thomas M. Trainer, D.C.
Telephone: 763-566-1042 Fax: 763-566-8090
E-mail: info@brookwestchiro.com
Address: 6800 78th Ave N Brooklyn Park, MN 55445
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