PINHOOK CHIROPRACTIC CLINIC
100 LA RUE FRANCE
LAFAYETTE, LA 70508
Phone (337)237-2273 Fax (337)237-1765
Effective October 1, 2013
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
The Practice (the “Practice”), in accordance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, (the “Privacy Rule”) and applicable state law, is committed to protecting the privacy of your protected health information (“PHI”). PHI includes information about your health condition and the care and treatment you receive from the Practice. The Practice understands that information about your health is personal. This Notice explains how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI. The Practice is required by law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practice’s legal duties and practices with respect to your PHI. The Practice is also required by law to abide by the terms of this Notice.
If you have any questions about this Notice please contact our Privacy Officer or any staff member in our office.
Our Privacy Officers are: KYLEEN BEEBE and SONYA RICHARD.
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 describes your rights to access and control your protected health information. "Protected Health Information" (PHI) 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 by accessing our website www.pinhookchiropractic.com
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.
HOW THE PRACTICE MAY USE AND
DISCLOSE YOUR PROTECTED HEALTH INFORMATION
General Use and Disclosures of Protected Health Information
By applying to be treated in our office, you are implying consent to the use and disclosure of your protected health information by your doctor, 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 practic
Uses and Disclosures of Protected Health Information Based Upon Your Implied Consent:
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.
The Practice, in accordance with this Notice and without asking for your express consent or authorization, may use and disclose your PHI for the purposes of:
Treatment amongst other Professionals: We may use your PHI to provide you with treatment. We may disclose your PHI to doctors, nurses, technicians, clinicians, medical students, hospitals and other health facilities involved in or consulting in your care. We may also disclose information about you to people outside the practice, such as other health care providers involved in providing treatment to you, and to people who may be involved in your care, such as family members, clergy, or others we use to provide services that are part of your care. If we refer you to another health care provider, we would, as part of the referral process share PHI information about you. For example, if you were referred to a specialist, we would contact the doctor’s office and provide such information about you to them so that they could provide services to 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 doctor, becomes involved in your care by providing assistance with your health care diagnosis or treatme
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.
Business Associate: We will share your protected health information with third party "business associates" that perform various activities (e.g., billing, transcription services for the practice).
A business associate is an entity that assists the Practice in undertaking some essential function, such as a billing company that assists the office in submitting claims for payment to insurance companies.
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.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of this office. These activities may include, but are not limited to, quality assessment activities, employee review activities and training of chiropractic students/interns. For example, we may disclose your protected health information to chiropractic interns or precepts that see patients at our office.
Appointment Reminders and Daily Treatment: We may use and disclose your PHI to remind you by telephone, text, mail, or e-mail about appointments you have with us, annual exams, or to follow up on missed or cancelled appointments.
Sign-In Procedures on Arrival: We may use a sign-in sheet or digital sign in pad at the registration desk where you will be asked to sign your name. We may also address you by name in the reception area to notify you that we are ready to proceed with your care.
Open and/or Common Treatment Rooms and Protocols: We do have open therapy/adjusting/treatment areas. Communications between you and the doctor or his assistants may be necessary to assist us in accurately capturing your responses associated with the treatment for that day. Should you elect to be treated in the open treatment region, we may contact you by name or discuss your daily treatment in order to accurately capture your responses associated with the treatment. Discretion will be used in regards to your protected health information.
Should you feel more comfortable and elect to be treated in a private treatment area, these rooms will be made available on request for the scheduled appointment time.
Uses and Disclosures of Protected Health Information That May Be Made Only 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.
Sale of Health Information: We will not sell your PHI without your written authorization. If you do authorize such a sale, the authorization will disclose that we will receive compensation for the information that you have authorized us to sell. You have the right to revoke the authorization at any time, which will halt any future sale.
Marketing Purposes / Notification of In Office Products, Services and/or Treatment Alternatives: We will not use or disclose your PHI for marketing purposes for which we have accepted payment without your express written permission. However, 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/or products/services that may be of interest to you. We may also send you information about products or services that we believe may be beneficial to you, your treatment, or your care.
We may also use and disclose your protected health information for other internal marketing activities. For example, your name, address, phone number, or email may be used to send you a newsletter or promotional notification about our practice and the services we offer. Your name, address, phone number or email may be used to send out annual birthday and/or holiday cards, etc…
If you do authorize a use and/or disclosure, you have the right to revoke that authorization at any time by submitting a revocation in writing to our Privacy Officer. You may revoke any of these authorizations, at any time, in writing, except to the extent that your doctor or the practice has taken an action in reliance on the use or disclosure indicated in the authorization. A revocation cannot be retroactive and will only impact uses and/or disclosures after the date of revocation.
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 doctor 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 or Payment for Your Care: 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 or general condition. 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.
Personal Representative: The Practice may use and disclose PHI to a person who, under applicable law, has the authority to represent you in making decisions related to your health care.
Emergency Situations: The Practice may use and disclose PHI for the purpose of obtaining or rendering emergency treatment to you provided that the Practice attempts to obtain your Consent as soon as possible.
Disaster Relief: We also may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts. This will be done to coordinate information with those organizations in notifying a family member, other relative, close friend or other individual of your location and general condition.
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. These activities generally include:
To prevent or control disease, injury or disability
To report births or deaths
To report child, elder, or dependent adult abuse or neglect
To report reactions to medications or problems with products
To notify people of recalls of products they may be usi
To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
To Avert Serious Threat to Health or Safety: We will use and disclose your PHI when we have a “duty to report” under state or federal law because we believe that it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure would be to help prevent a threat.
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.
Victims of Abuse, Neglect or Domestic Violence: We may disclose your PHI to a government authority authorized by law to receive reports of abuse, neglect, or domestic violence, if we believe an adult or child is a victim of abuse, neglect, or domestic violence. This will occur to the extent the disclosure is (a) required by law, (b) agreed to by you, (c) authorized by law and we believe the disclosure is necessary to prevent serious harm, or, (d) if you are incapacitated and certain other conditions are met, a law enforcement or other public official represents that immediate enforcement activity depends on the disclosure.
Coroners, Medical Examiners and Funeral Directors: We may disclose your PHI to a coroner or medical examiner for purposes such as identifying a deceased person and determining cause of death. We also may disclose information to funeral directors so they can carry out their duties.
Organ, Eye or Tissue Donation: To facilitate organ, eye or tissue donation and transplantation, we may disclose your PHI to organizations that handle organ procurement, banking or transplantation.
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.
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. We may disclose your PHI to law enforcement officials for these purposes:
- In response to a court, grand jury or administrative order, warrant or subpoena
- To identify or locate a suspect, fugitive, material witness or missing person
- About an actual or suspected victim of a crime if, under certain limited circumstances, we are unable to obtain that person’s agreement
- To alert a potential victim or victims or intending harm (“duty to warn”)
- To alert law enforcement officials to a death if we suspect the death may have resulted from criminal conduct
- About crimes that occur at our facilities
- To report a crime, a victim of a crime or a person who committed a crime in emergency circumstances
Workers' Compensation: We may disclose your protected health information, as authorized, to comply with workers' compensation laws and other similar legally-established programs.
Special Government Functions: If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release information about foreign military authority. We may disclose information about you to authorized federal officials for intelligence, counter-intelligence and other national security activities authorized by law.
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.
De-identified Information: The Practice may use and disclose health information that may be related to your care but does not identify you and cannot be used to identify you.
Research: We may use and/or disclose your PHI for research projects that are subject to a special review process. If researchers are allowed access to information that identifies who you are, we will ask for your permission.
Fundraising: We may contact you with respect to fundraising campaigns. If you do not wish to be contacted for fundraising campaigns, please notify our Privacy Officer in writing.
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.
Right to Revoke Authorization:
You have the right to revoke any Authorization or consent you have given to the Practice, at any time. To request a revocation, you must submit a written request to the Practice’s Privacy Officer.
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 doctor 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 complied 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 reviewed. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer, if you have questions about access to your medical record.
To inspect or copy your information, you may either complete an Authorization to Release/Obtain Information form or write a letter of request, stating the type of information to be released, the date(s) of service being requested, the purpose of the request, and whether you wish to review the record or receive copies of the requested information in your preferred format. We will abide by your request in the format you have requested, if we are able to do so. If we cannot provide your records to you in the requested format, we will attempt to provide them in an alternative format that you agree to. You may also request that your records be sent to another person that you have designated in writing. Direct this request to the Practice’s Privacy Officer. You may be charged a fee for the cost of copying, mailing or other expenses related with your request.
We may deny your request to inspect and copy information in a few limited situations. If you request is denied, you may ask for our decision to be reviewed. The Practice will choose a licensed health care professional to review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of that review
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 have the right to restrict certain disclosures of Protected Health Information to a health plan when you pay out of pocket in full for the healthcare delivered by our office and we will abide by that request unless we are legally obligated to do so. 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. You may opt out of fundraising communications in which our office participates.
We are not required to agree to any other requested restriction. If the doctor 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 we agree, we will follow your request unless the information is needed to a) give you emergency treatment, b) report to the Department of Health and Human Services, or c) the disclosure is described in the “Uses and Disclosures That Are Required or Permitted by Law” section.
With this in mind, please discuss any restriction you wish to request with your doctor.
You may request a restriction by presenting your request, in writing to the staff member identified as "Privacy Officer" at the top of this form. The Privacy Officer will provide you with "Restriction of Consent" form. Complete the form, sign it, and 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:
You have the right to request that we communicate your PHI in a certain way or at a certain place. For example, you can ask that we only contact you by mail or at work.
If you want to request confidential communications you must do so in writing to our Practice’s Privacy Officer and explain how or where you can be contacted. 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.
You may have the right to have your doctor amend your protected health information:
If you feel that your PHI is incorrect, you have the right to ask us to amend it, for as long as the information is maintained by us. To request an amendment, you must submit your request in writing to the Practice’s Privacy Officer. You must provide a reason for the amendment.
We may deny your request for an amendment if it is not in writing or does not include a reason for wanting the amendment. We also may deny your request if the information: a) was not created by us, unless the person or entity that created the information is no longer available to amend the information, b) is not part of the information maintained by the Practice, c) is not information that you would be permitted to inspect and copy or d) is accurate and complete.
If your request is granted the Practice will make the appropriate changes and inform you and others, as needed or required. If we deny your request, we will explain the denial in writing to you and explain any further steps you may wish to take. 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 Officer 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:
You have the right to request an accounting of disclosures. This is a list of certain disclosures we have made regarding your PHI.
Certain types of disclosures are not included in such an accounting. These include disclosures made for treatment, payment or healthcare operations; disclosures made to you or for our facility directory; disclosures made with your authorization; disclosures for national security or intelligence purposes or to correctional institutions or law enforcement officials in some circumstances. It excludes disclosures we may have made to you, to family members or friends involved in your care, pursuant to a duly executed authorization or for notification purposes.
To request an accounting of disclosures, you must write to the Practice’s Privacy Officer. Your request must state a time period for the disclosures. The time period may be for up to six years prior to the date on which you request the list, but may not include disclosures made before April 14, 2003.
There is no charge for the first list we provide to you in any 12-month period. For additional lists, we may charge you for the cost of providing the list. If there will be a charge, we will notify you of the cost in advance. You may withdraw or change your request to avoid or reduce the fee.
The right to receive this information is subject to certain exceptions, restrictions and limits.
Right to a Paper Copy of this Notice:
You have the right to receive a paper copy of this Notice of Privacy Practices, even if you have agreed to receive this Notice electronically. You may request a paper copy of this Notice at any time.
Right to File a Complaint:
You have the right to complain to the Practice or to the United States Secretary of Health and Human Services (as provided by the Privacy Rule) if you believe your privacy rights have been violated. We will not retaliate against you for filing a complaint.
To file a complaint with the Practice, you must contact the Practice’s Privacy Officer. To obtain more information about your privacy rights or if you have questions about your privacy rights you may contact the Practice’s Privacy Officer as follows:
Name: Pinhook Chiropractic Clinic
Attn: HIPAA Compliance Officer: Kyleen Beebe or Sonya Richard
Address: 100 La Rue France, Lafayette, LA 70508
Telephone No. :( 337) 237-2273
To file a complaint with the United States Secretary of Health and Human Services, you may write to:
Office for Civil Rights, U.S. Department of Health and Human Services
200 Independence Avenue
S.W., Washington, DC 20201.
All complaints must be in writing.
You have the right to be notified by our office of any breech of privacy of your Protected Health Information.
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.
This notice was published and becomes effective on October 1, 2013.
This notice was last updated on March 6, 2015.