NOTICE OF PRIVACY PRACTICES
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.
I. Who We Are
Chiropractic Performance Solutions (KET Chiropractic Center )
Chiropractic Performance Solutions
24120 Meadowbrook Rd. , Suite 200
Novi, MI 48375
This Notice describes the privacy practices of KET Chiropractic Center. If you have any questions about this notice, please contact our Privacy Contact who is Jennifer Mannan.
II. Our Privacy Obligations
We are required by law to maintain the privacy of your health information (“Protected Health Information” or “PHI”) and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).
III. Permissible Uses and Disclosures Without Your Written Authorization
Subject to the limitations, which we will describe in Section IV below, we may use and/or disclose your PHI without your written permission for the following purposes:
A. Uses and Disclosures For Treatment, Payment and Health Care Operations. We may use and disclose PHI in order to treat you, obtain payment for services provided to you and conduct our “health care operations” as detailed below:
Treatment. We may use and disclose your PHI to provide treatment and other services to you–for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also disclose PHI to other providers involved in your treatment.
Payment. We may use and disclose your PHI to obtain payment for services that we provide to you–for example, disclosures to claim and obtain payment from your health insurer, or other company that arranges or pays the cost of some or all of your health care to verify that they will pay for your health care.
Health Care Operations. We may use and disclose your PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use PHI to evaluate the quality and competence of our doctors, therapists and other staff.
We may also disclose PHI to another health care facility to which you have been referred when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.
B. Public Health Activities. We may disclose your PHI for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.
C. Victims of Abuse or Neglect. If we reasonably believe you are a victim of abuse or neglect, we may disclose your PHI to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse or neglect.
D. Health Oversight Activities. We may disclose your PHI to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid and civil rights laws.
E. Judicial and Administrative Proceedings. We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
F. Law Enforcement Officials. We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
G. Decedents. We may disclose your PHI to a funeral director or medical examiner as authorized by law.
H. Organ and Tissue Procurement. We may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
I. Research. We may use or disclose your PHI for research purposes with your consent or we will ask an institutional review board to approve a waiver of authorization for disclosure. A waiver of authorization will be based upon assurances from the review board that the researchers will adequately protect your PHI. J. Health or Safety. We may, consistent with applicable law and standards of ethical conduct, use or disclose your PHI to prevent or lessen a threat of imminent, serious physical violence against you or another readily identifiable individual.
K. Specialized Government Functions. We may use and disclose your PHI to units of the government with special functions, such as the U.S. military or the U.S. Department of State under certain circumstances.
L. Workers’ Compensation. We may disclose your PHI as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs.
M. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
N. As required by law. We may use and disclose your PHI when required to do so by any other law not already referred to in the preceding categories.
IV. Uses and Disclosures Requiring Your Written Authorization
This Section IV describes when we must obtain your written permission to use or disclose your PHI.
A. Use or Disclosure with Your Authorization. For any purpose other than the ones described above in Section III and in this Section IV, we only may use or disclose your PHI when you grant us your written authorization on our authorization form. For example, you will need to complete and sign an authorization form before we can send your PHI to the attorney representing the other party in litigation in which you are involved.
B. Marketing. We must also obtain your written authorization prior to using your PHI to send you any marketing materials. (We can, however, provide you with marketing materials in a face-to-face encounter, or in the form of a promotional gift of nominal value, without obtaining your authorization.)
C. Communicable Disease Information. Your Authorization must expressly refer to your communicable disease information in order to permit us to disclose any information identifying you as having or being suspected of having a communicable disease. However, there are certain purposes for which we may disclose your communicable disease information, without obtaining your Authorization, including to a prosecuting officer or the court if you are being prosecuted under Michigan law, to the Department of Health and Social Services, or to your physician or a health authority, such as the local board of health. Your physician or a health authority may disclose your communicable disease information only if he/she/it deems it necessary in order to protect the health or welfare of you, your family or the public.
D. Substance Abuse Information. The confidentiality of alcohol and drug abuse patient records maintained by us is protected by federal law and regulations. Generally, we may not say to any person outside our facilities that a patient attends our facilities, or disclose any information identifying a patient as an alcohol or drug abuser unless the patient consents in writing, the disclosure is allowed by court order, or the disclosure is made to medical personnel in a medial emergency or to qualified personnel for research, audit or program evaluation. Accordingly, we may not disclose drug and alcohol medical records without your Authorization.
V. Your Rights Regarding Your Protected Health Information
A. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact us. You may also file written complaints with the Secretary of Health and Human Services. We will not retaliate against you if you file a complaint with the Secretary or us.
B. Right to Request Restrictions. You may request restrictions on our use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for restrictions carefully, we are not required to agree to a requested restriction. If you wish to request restrictions, please obtain a request form from our Privacy Contact and submit the completed form to us. If we agree to the requested restrictions, we will comply with your request unless PHI is needed for emergency treatment.
C. Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations. If you wish to make a request, please contact our Privacy Contact in writing.
D. Right to Revoke Your Authorization. You may revoke your Authorization or your Marketing Authorization, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Contact identified below.
E. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records.
F. Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Privacy Contact and submit the completed form to us. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
G. Right to Receive An Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. The accounting will not include uses or disclosures for treatment, payment, or healthcare operations, or uses or disclosures pursuant to an authorization you have already provided.
H. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
VI. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective on April 14, 2003.
B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in our waiting areas and on our Internet site at www.chiropracticperformancesolutions.com You also may obtain any new notice by contacting the Privacy Office.
VII. Privacy Contact
You may contact the Privacy Contact at:
Chiropractic Performance Solutions (KET Chiropractic Center)
24120 Meadowbrook, Suite 200
Novi, MI 48375
Telephone Number: (248) 477-2100