Privacy Notice
Brist Chiropractic & Naturopathic
Nutrition Center
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.
Brist Chiropractic &
Naturopathic Nutrition Center (BC&NNC) is required, by law, to maintain the
privacy and confidentiality of your protected health information and to provide
our patients with notice of our legal duties and privacy practices with respect
to your protected health information.
Disclosure of Your Health Care Information
Treatment
We may disclose your health
care information to other healthcare professionals within our practice for the
purpose of treatment, payment or healthcare operations.
“On
occasion, it may be necessary to seek consultation regarding your condition
from other health care providers associated with BC&NNC.”
“It
is our policy to provide a substitute health care provider, authorized by
BC&NNC to provide assessment and/or treatment to our patients, without
advanced notice, in the event of your primary health care provider’s absence
due to vacation, sickness, or other emergency situation.”
Payment
We may disclose your health information to your insurance provider for
the purpose of payment or health care operations.
“As
a courtesy to our patients, we will submit an itemized billing statement to
your insurance carrier for the purpose of payment to BC&NNC for health care
services rendered.If you pay for your
health care services personally, we will, as a courtesy, provide an itemized
billing to your insurance carrier for the purpose of reimbursement to you. The
billing statement contains medical information, including diagnosis, date of
injury or condition, and codes which describe the health care services
received.”
Workers’ Compensation
We may disclose your health
information as necessary to comply with State Workers’ Compensation Laws.
Emergencies
We may disclose your health
information to notify or assist in notifying a family member, or another person
responsible for your care about your medical condition or in the event of an
emergency or of your death.
Public Health
As
required by law, we may disclose your health information to public health
authorities for purposes related to:preventing
or controlling disease, injury or disability, reporting child abuse or neglect,
reporting domestic violence, reporting to the Food and Drug Administration
problems with products and reactions to medications, and reporting disease or
infection exposure.
Judicial and Administrative Proceedings.
We
may disclose your health information in the course of any administrative or
judicial proceeding.
Law Enforcement.
We
may disclose your health information to a law enforcement official for purposes
such as identifying or locating a suspect, fugitive, material witness or
missing person, complying with a court order or subpoena, and other law
enforcement purposes.
Deceased Persons.
We
may disclose your health information to coroners or medical examiners.
Organ Donation.
We
may disclose your health information to organizations involved in procuring,
banking, or transplanting organs and tissues.
Research.
We
may disclose your health information to researchers conducting research that
has been approved by an Institutional Review Board.
Public Safety.
It may be necessary to
disclose your health information to appropriate persons in order to prevent or
lessen a serious and imminent threat to the health or safety of a particular
person or to the general public.
Specialized Government Agencies.
We may disclose your health information for military,
national security, prisoner and government benefits purposes.
Marketing.
We may contact you for
marketing purposes or fundraising purposes, as described below:
“As
a courtesy to our patients, it is our policy to call your home on the evening
prior to your scheduled appointment to remind you of your appointment time. If
you are not at home, we leave a reminder message on your answering machine or
with the person answering the phone. No personal health information will be
disclosed during this recording or message other than the date and time of your
scheduled appointment along with a request to call our office if you need to
cancel or reschedule your appointment.”
“It
is our practice to participate in charitable events to raise awareness, food
donations, gifts, money, etc. During these times, we may send you a letter,
post card, invitation or call your home to invite you to participate in the
charitable activity.We will provide
you with information about the type of activity, the dates and times, and
request your participation in such an event.It is not our policy to disclose any personal health information about
your condition for the purpose of BC&NNC sponsored fund-raising events.”
“We
send out regular newsletters, flyers, postcards, letters and e-mail updates
regarding health issues that may be of interest to you. We may invite you to
take advantage of special offers for products or services. These communications
will not contain any information specific to your own health.
Change of Ownership.
In
the event that BC&NNC is sold or
merged with another organization, your health information/record will become
the property of the new owner.
Your Health Information Rights
ØYou have the right to request restrictions on certain
uses and disclosures of your health information.Please be advised, however, that BC&NNC is not required to
agree to the restriction that you requested.
ØYou have the right to have your health information
received or communicated through an alternative method or sent to an
alternative location other than the usual method of communication or delivery,
upon your request.
ØYou have the right to inspect and copy your health
information.
ØYou have a right to request that BC&NNC amend your
protected health information. Please be advised, however, that BC&NNC is
not required to agree to amend your protected health information. If your
request to amend your health information has been denied, you will be provided
with an explanation of our denial reason(s)and information about how you can
disagree with the denial.
ØYou have a right to receive an accounting of
disclosures of your protected health information made by BC&NNC.
ØYou have a right to a paper copy of this Notice of
Privacy Practices at any time upon request.
Changes to this Notice of Privacy Practices
BC&NNC
reserves the right to amend this Notice of Privacy Practices at any time in the
future, and will make the new provisions effective for all information that it
maintains. Until such amendment is made, BC&NNC is required by law to
comply with this Notice.
BC&NNC
is required by law to maintain the privacy of your health information and to
provide you with notice of its legal duties and privacy practices with respect
to your health information.If you have
questions about any part of this notice or if you want more information about
your privacy rights, please contact: BC&NNC by calling this office at
763-546-9151. If BC&NNC is not available, you may make an appointment for a
personal conference in person or by telephone within 2 working days.
Complaints
Complaints
about your Privacy rights, or how BC&NNC has handled your health
information should be directed to Cheri Rivers by calling this office at
763-546-9151. If Cheri is not available, you may make an appointment for a
personal conference in person or by telephone within 2 working days.
If you are not satisfied with the manner in which this
office handles your complaint, you may submit a formal complaint to:
DHHS, Office of Civil
Rights
200 Independence
Avenue, S.W.
Room 509F HHH Building
Washington, DC20201
This notice is effective as
April 14, 2003.
I have read the Privacy
Notice and understand my rights contained in the notice.
By way of my signature, I
provide BC&NNC with my authorization and consent to use and disclosed my
protected health care information for the purposes of treatment, payment and
health care operations as described in the Privacy Notice.
________________________________________________
Patient’s Name (print)
______________________________________________________________
Patient’s SignatureDate
______________________________________________________________
Authorized Facility SignatureDate
