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Sweet Chiropractic
Dr. Jay Sweet, D.C.
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FORM: NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW
HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
Jay Sweet, DC respects your privacy. We understand that your personal
health information is very sensitive. We will not disclose your information to
others unless you tell us to do so, or unless the law authorizes or requires us
to do so.
The law protects the
privacy of the health information we create and obtain in providing our care
and services to you. For example, your protected health information includes
your symptoms, test results, diagnoses, treatment, health information from
other providers, and billing and payment information relating to these
services. Federal and state law allows us to use and disclose your protected
health information for purposes of treatment and health care operations. State
law requires us to get your authorization to disclose this information for
payment purposes.
Examples of Use and
Disclosures of Protected Health Information for Treatment, Payment, and Health
Operations
For treatment:
- Information obtained by a nurse,
physician, or other member of our health care team will be recorded in
your health record and used to help decide what care may be right for you.
- We may also provide information to
others providing you care. This will help them stay informed about your
care.
For payment:
- We request payment from your health
insurance plan. Health plans need information from us about your health
care. Information provided to health plans may include your diagnoses;
procedures performed, or recommended care.
For health care operations:
- We use your health records to assess
quality and improve services.
- We may use and disclose health records
to review the qualifications and performance of our health care providers
and to train our staff.
- We may contact you to remind you about appointments
and give you information about treatment alternatives or other health-related benefits and
services.
- We may contact you to raise funds.
- We may use and disclose your
information to conduct or arrange for services, including:
- health quality review by your health
plan;
- accounting, legal, risk management,
and insurance services;
- audit functions, including fraud and
abuse detection and compliance programs.
Your Health Information Rights
The health and
billing records we create and store are the property of the practice/health
care facility. The protected health information in it, however, generally
belongs to you. You have a right to:
- Receive, read, and ask questions about
this Notice;
- Ask us to restrict certain uses and
disclosures. You must deliver this request in writing to us. We are not required
to grant the request. But we will comply with any request granted;
- Request and receive from us a paper
copy of the most current Notice of Privacy Practices for Protected Health
Information (“Notice”);
- Request that you be allowed to see and
get a copy of your protected health information. You may make this request
in writing. We have a form available for this type of request.
- Have us review a denial of access to
your health information—except in certain circumstances;
- Ask us to change your health information.
You may give us this request in writing. You may write a statement of
disagreement if your request is denied. It will be stored in your health
record, and included with any release of your records.
- When you request, we will give you a
list of disclosures of your health information. The list will not include
disclosures to third party payors. You may receive this information
without charge once every 12 months. We will notify you of the cost
involved if you request this information more than once in 12 months.
- Ask that your health information be
given to you by another means or at another location. Please sign, date,
and give us your request in writing.
- Cancel prior authorizations to use or
disclose health information by giving us a written revocation. Your
revocation does not affect information that has already been released. It
also does not affect any action taken before we have it. Sometimes, you
cannot cancel an authorization if its purpose was to obtain insurance.
For help with these
rights during normal business hours, please contact:
Our Responsibilities
We are required to:
- Keep your protected health information
private;
- Give you this Notice;
- Follow the terms of this Notice.
We have the right to
change our practices regarding the protected health information we maintain. If
we make changes, we will update this Notice. You may receive the most recent
copy of this Notice by calling and asking for it or by visiting our
(office/health records department) to pick one up.
To Ask for Help or Complain
If you have
questions, want more information, or want to report a problem about the
handling of your protected health information, you may contact:
Jay Sweet, DC
3535 Martin Way E,
Olympia,
WA 98506
If you believe your
privacy rights have been violated, you may discuss
your concerns with any staff member. You may also deliver a written
complaint to [name or title of person] at
our practice/health care facility. You may also file a complaint with the U.S.
Secretary of Health and Human Services.
We respect your right to file a complaint with us or
with the U.S. Secretary of Health and Human Services. If you complain, we will
not retaliate against you.
Other Disclosures and Uses of Protected Health Information
Notification of
Family and Others
- Unless you object, we may release
health information about you to a friend or family member who is involved
in your health care. We may also give information to someone who helps pay
for your care. We may tell your family or friends your condition and that
you are in a hospital. In addition, we may disclose health information
about you to assist in disaster relief efforts.
- [Hospitals] Information may be
provided to people who ask for you by name. We may use and disclose the
following information in a hospital directory:
- your name,
- location,
- general condition, and
- Religion (only to clergy).
You have the right to object to this use or disclosure of your
information. If you object, we will not use or disclose it.
We may use and disclose your protected health
information without your authorization as follows:
- With health researchers—if
the research has been approved and has policies to protect the privacy of your
health information. We may also share information with health researchers
preparing to conduct a research project.
- To Funeral Directors/Coroners
consistent with applicable law to allow them to carry out their duties.
- To Organ Procurement Organizations
(tissue donation and transplant) or persons who obtain, store, or
transplant organs.
- To the Food and Drug Administration
(FDA) relating to problems with food, supplements, and products.
- To comply with workers’ compensation
laws--if you make a workers’ compensation claim.
- For Public Health and Safety purposes
as allowed or required by law:
- to prevent or reduce a serious,
immediate threat to the health or safety of a person or the public.
- to public health or legal authorities
- to protect public health and safety
- to prevent or control disease,
injury, or disability
- to report vital statistics such as
births or deaths.
- To report suspected Abuse or Neglect
to public authorities.
- To Correctional Institutions if you
are in jail or prison, as necessary for your health and the health and
safety of others.
- For Law Enforcement purposes such as
when we receive a subpoena, court order, or other legal process, or you
are the victim of a crime.
- For Health and Safety oversight
activities. For example, we may share health information with the
Department of Health.
- For Disaster Relief Purposes. For
example, we may share health information with disaster relief agencies to
assist in notification of your condition to family or others.
- For Work-Related Conditions That Could
Affect Employee Health. For example, an employer may ask us to assess
health risks on a job site.
- To the Military Authorities of U.S.
and Foreign Military Personnel. For example, the law may require us to
provide information necessary to a military mission.
- In the Course of
Judicial/Administrative Proceedings at your request, or as directed by a
subpoena or court order.
- For Specialized Government Functions.
For example, we may share information for national security purposes.
Other Uses and
Disclosures of Protected Health Information
- Uses and disclosures not in this
Notice will be made only as allowed or required by law or with your
written authorization.
Web Site
- We have a Web site that provides
information about us. For your benefit, this Notice is on the Web site at
this address: www.DrSweetDC.com.
Effective Date:
4-14-03
Notice of Privacy Practices
-- Acknowledgement
We keep a record of
the health care services we provide you. You may ask to see and copy that
record. You may also ask to correct that record. We will not disclose your
record to others unless you direct us to do so or unless the law authorizes or
compels us to do so. You may see your record or get more information about it
by contacting (name or title of Privacy Officer)
Our Notice of Privacy
Practices describes in more detail how your health information may be used and
disclosed, and how you can access your information.
By my signature below I acknowledge receipt of the Notice of Privacy
Practices.
__________________________________________ _______________
Signature of patient
or authorized representative
Date
_____________________________ _______________________________________
Printed name if
signed on behalf of patient / Relationship (parent, legal guardian, personal
representative, etc.)
(Notation, if any, by
staff)
This form will be retained in your health
record.
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