This office is required by law, to notify you in writing, we must maintain the privacy and confidentiality of your Personal Health Information. In addition, we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictacted b y our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a summary of the circumsance, if you would like a more detailed explanation, one will be provided to you. In
Permitted Disclosures:
1. Treatment purposes: discussion with other health care providers invovled in your care
2. Inadvertent disclosures: open treating area means open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consulation room.
3. For payment purposes: to obtain payment from your insurance company or any other collateral source
4. For workers compensation purposes: to process a claim or aid in investigation
5. Emergency: in the event of a medical emergency we may notify a family member
6. For public health and safety: to prevent or lessen a serious or eminent threat to the health of safety of a person or general public
7. To Government agencies or Law enforcement: to identify or locate a suspect, fugitive, material witness or missing person.
8. For military, national security, prisoner, and government benefits purposes.
9. Deceased persons- discussion with coroners and medical examiners in the event of a patients death.
10. Telephone calls or emails and appointment reminders- we may call your home and leavge a message regarding missed appointments or apprize you of changes in practice hours or upcoming events.
11. Change of ownership- in the event this practice is sold, the new owners would have access to your PHI.
YOUR RIGHTS:
1. To receive an accounting of disclosures.
2. To receieve a paper copy of the comprehensive "Detail" Privacy Notice
3. To request mailings to an address different than residence
4. To request Restrictions on certain uses and disclosures and whith whom we release information to, although we are not required to comply, if however, we agree, the restriction will be in place until written notice of your intent to remove said restriction.
5. To inspect your records and receive one copy of your records at no charge, with notice in advance
6. To request amendments to information. However, like restrictions, we are not required to agree to them.
7. To obtain ONE copy of your records at no charge, when timely notice is provided (72 hours). X-rays are original records and you are therefore not entitled to them. If you would like us to out source them to an imaging center, to have copies made, we will be happy to accomidate you. However, you will be responsible for the cost.
COMPLAINTS: If you wish to make a formal complaint about how we handle your health information, please call Benjamin Fehr at (360) 348-8970. If he is unavailable, you can make an appointment with our receptionist to speak with him within 72 hours or 3 work days. If you are still not satisfied with the way this office handles your complaint, you can submit a formal complaint to: DHHS, Office of Civil Rights, 2oo Independence Ave. SW, Room 509F HHH Building, Washington DC 20201.
I have received a copy of Primal Chiropractic's Patient Private Notice. I understand my rights as well as the practicfes duty to protect my hralth information, and havef conveyed my understanding of these rights and duties to the doctor. I further understand that this office has the right to amend this 'Notice of Privacy Practice' at any time in the future, and will make the new provisions effective for all information that it maintains past and present. At this time, I do not have any questions regarding my rights or any of the information I have recieved.