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. This Notice of Privacy Practices describes how Reignite Chiropractic LLC (RC) may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your right to access and control your PHI that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.
USES AND DlSCLOSURES OF PROTECTED HEALTH INFORMATION
Your PHI may be used and disclosed by your physician, RC 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, to pay your health care bills, to support the operation of RC, and other use required by law.
TREATMENT: RC will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, RC would disclose your PHI, as necessary, to a home health agency that provides care to you, or to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
PAYMENT: Your PHI will be used, as needed, to obtain payment from your insurance company for your health care services. For example, obtaining approval for a hospital stay may require that your relevant PHI be disclosed to the health plan to obtain approval for the hospital admission.
HEALTHCARE OPERATIONS: RC may use or disclose, as needed, your protected health information in order to support the business activities of RC. These activities include, but are not limited to: (a) quality assessment activities; (b) employee review activities; (c) training of medical students; and (d) licensing and conducting or arranging for other business activities. For example, RC may disclose your PHI to medical school students that see patients at the office. In addition, RC may use a sign-in sheet at the registration desk where you will be asked to sign your name, may call you by name in the waiting room when your physician is ready to see you, may use or disclose your PHI as necessary to contact you to remind you of your appointment by leaving a message on a recorded answering system at your home of office.
At RC, it is the practice of this office to provide chiropractic care in a "semi-dosed" environment. "Semi-dosed" adjusting involves patient care in a setting where other patients in the reception area are able to see into the adjusting rooms, as well as possibly hear what is being discussed in the adjustment room. This environment is used for ongoing care and is NOT used for initial examination and patient history consultation. We are requesting this authorization of you due to various interpretations under federal law with respect to what is known as "incidental disclosure" of health information. I accept and agree to being treated in this "semi-closed" environment and understand the potential risk for incidental disclosure and do not hold Reignite Chiropractic liable for such actions.
I give RC permission to use my address, phone number, and clinical records to contact me with appointment reminders, missed appointment notification, birthday cards, holiday related cards, newsletters, information about treatment alternatives, or other health related information.
If RC contacts me by phone, I give them permission to leave a message on my voicemail or answering machine.
I give RC permission to use my name on the welcome board, referral board, birthday board, prize winning notices, and community information (i.e. newspaper clippings).
I give RC permission to adjust me in a semi-closed room setting where other patients and office staff may able to overhear some of my PHI during the course of care. This semi-closed room environment is used for ongoing care, and is not the environment used for taking patient histories, performing examinations, or
presenting report of findings, as these procedures are completed in a private, confidential setting.
RC may use or disclose your PHI in the following situations without your authorization. These situations include: as required by law; public health issues; communicable diseases; health oversight; abuse or neglect; Food and Drug Administration requirements; legal proceedings; law enforcement; coroner; funeral
directors, organ donation; research; criminal activity; military activity, National security; workers' compensation, Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Department of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.
Other permitted and required uses and disclosures will be made only with your consent, authorization, or opportunity to object unless required by law.
You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.
YOUR RIGHTS:
Following is a statement of your rights with respect to your PHI.
You have the right to inspect and copy your PHI. However, in accordance with federal law, you may not inspect and copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI.
You have the right to request a restriction or your PHI. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment, or health care operations. You may also request that any part of your PHI 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 state specific restrictions requested and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If physician 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. You then have the right to use another health care professional.
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 obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice in an alternative medium, such as electronically.
You may have the right to have your physician amend your PHI. 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 such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
COMPLAINTS
If you believe that Reignite Chiropractic LLC has violated your privacy rights, you may file a complaint with Jacob Ussery, D.C. at Reignite Chiropractic LLC at 2717 John Hawkins PKWY, Suite 107, Hoover, AL 35244, or you file a complaint with the Secretary of Health and Human Services, at 200 Independence Avenue SW, Washington DC 20201.
I have read, understand, and agree to the aforementioned HIPAA regulations.