-Camanche Chiropractic Center
Drs. Gary & Mark Parsons

PRIVACY NOTICE TO PATIENTS

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

POLICY STATEMENT

This Practice is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about your medical condition and the care and treatment you receive from the Practice and other health care providers. This Notice details how your PHI may be used and disclosed to third parties for purposes of your care, payment for your care, health care operations of the Practice, and for other purposes permitted or required by law. This Notice also details
your rights regarding your PHI.

USE OR DISCLOSURE OF PHI

The Practice may use and/or disclose your PHI for purposes related to your care, payment for your care, and health care operations of the Practice. The following are examples of the types of uses and/or disclosures of your PHI that may occur. These examples are not meant to include all possible types of use and/or disclosure. Care – Payment – Health Care Operations –.

AUTHORIZATION NOT REQUIRED

The Practice may use and/or disclose your PHI, without a written Authorization from you, in the following instances:

De-identified Information – Business Associate – Personal Representative – Public Health Activities – Federal Drug Administration –,.Abuse, Neglect or Domestic Violence – Health Oversight Activities – Judicial and Administrative Proceeding – Law Enforcement Purposes – Coroner or Medical Examiner – Organ, Eye or Tissue Donation – Research – Avert a Threat to Health or Safety – Specialized Government Functions – Inmates – Workers’ Compensation Disaster Relief Efforts – Required by Law

AUTHORIZATION

Uses and/or disclosures, other than those described above, will be made only with your written Authorization, which you may revoke at any time.

APPOINTMENT REMINDER

The Practice may, from time to time, contact you to provide appointment reminders. The reminder may be in the form of a letter or postcard. The Practice will try to minimize the amount of information contained in the reminder. The Practice may also contact you by phone and, if you are not available, the Practice will leave a message for you.

TREATMENT ALTERNATIVES/BENEFITS

The Practice may, from time to time, contact you about treatment alternatives, or other health benefits or services that may be of interest to you.

YOUR RIGHTS You have the right to:

  1. Revoke any Authorization, in writing, at any time. To request a revocation, you must submit a written request to the Practice’s Privacy Officer.

  2. Request restrictions on certain use and/or disclosure of your PHI as provided by law. However, the Practice is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to the Practice’s Privacy Officer. In your written request, you must inform the Practice of what information you want to limit, whether you want to limit the Practice’s use or disclosure, or both, and to whom you want the limits to apply. If the Practice agrees to your request, the Practice will comply with your request unless the information is needed in order to provide you with emergency treatment.

  3. Receive confidential communications of PHI by alternative means or at alternative locations. You must make your request in writing to the Practice’s Privacy Officer. The Practice will accommodate all reasonable requests.

  4. Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you must submit a written request to the Practice’s Privacy Officer. In certain situations that are defined by law, the Practice may deny your request, but you will have the right to have the denial reviewed. The Practice can charge you a fee for the cost of copying, mailing or other supplies associated with your request.

  5. Amend your PHI as provided by law. To request an amendment, you must submit a written request to the Practice’s Privacy Officer. You must provide a reason that supports your request. The Practice may deny your request if it is not in writing, if you do not provide a reason and support of your request, if the information to be amended was not created by the Practice (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 Practice, 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 Practice’s denial, you have the right to submit a written statement of disagreement.

  6. Receive an accounting of disclosures of your PHI as provided by law. To request an accounting, you must submit a written request to the Practice’s Privacy Officer. The request must state a time period which may not be longer than six years and may not include the dates before April 14, 2003. The request should indicate in what form you want the list (such as a paper or electronic copy). The first list you request within a 12 month period will be free, but the Practice may charge you for the cost of providing additional lists in that same 12 month period. The Practice will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred.

  7. Receive a paper copy of this Privacy Notice from the Practice upon request to the Practice’s Privacy Officer.

  8. Complain to the Practice, or to the Secretary of Health and Human Services, Office of Civil Rights, Hubert H. Humphrey Building, 200 Independence Avenue, S. W., Room 509F HHH Building, Washington, D.C. 20201. Or you may contact a regional office of the Office of Civil Rights, which can be found at www.hhs.gov/ocr/regmail.html. To file a complaint with the Practice, you must contact the Practice’s Privacy Officer. All complaints must be in writing.

  9. To obtain more information on, or have your questions about your rights answered; you may contact the Practice’s Privacy Officer, Dr. Gary Parsons at 1601 S. Wash. Blvd. Camanche IA or Email gparsons@jdv.net.

PRACTICE’S REQUIREMENTS

The Practice:

  1. Is required by law to maintain the privacy of your PHI and to provide you with this Privacy Notice of the Practice’s legal duties and privacy practices with respect to your PHI.

  2. Is required to abide by the terms of this Privacy Notice.

  3. Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.

  4. Will not retaliate against you for making a complaint.

  5. Must make a good faith effort to obtain from you an acknowledgement of receipt of this Notice.

  6. Will post this Privacy Notice on the Practice’s web site, if the Practice maintains a web site.

  7. Will provide this Privacy Notice to you by e-mail if you so request. However, you also have the right to obtain a paper copy of this Privacy Notice.

EFFECTIVE DATE This Notice is effective as of April 14, 2003.
ACKNOWLEDGEMENT

I acknowledge that I have received a copy of the Practice’s Privacy Notice that has an effective date of April, 14, 2003.
_________________________________ ___________________________________

Name of Individual (Printed) Signature of Individual
Date Signed _____/_____/________