Grosse Ile Family Chiropractic Bertie R. Synowiec, MS, DC
HIPAA Notice of Privacy Practices - Please read carefully
This Notice of Privacy Practices
describes how we may use/disclose your protected health information (PHI) to carry out treatment, payment or health care options and for other purposes that are permitted or required by law. It also describes your rights to access andcontrol your protected health information. Protected health information is information about you, including demographic informationthat may identify you and that relates to your past, present or future physical or mental health or condition and related health services.
Uses and Disclosures of Protected Health Information:
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providinghealth care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other userequired by law.
We will use and disclose your PHI to provide, coordinate, or manage your health care and any related servicesincluding the coordination or management of your health care with a third party such as a home health agency, or to your physician in the case of a referral, to ensure that the physician has the necessary information to diagnose or treat you.
Your PHI will be used, as needed, to obtain payment for your health care services. For example, to obtainapproval from your provider for services rendered.
• Healthcare Operations:
We may use your PHI for employee review and quality assessment activities within our chiropractic business. In addition we may utilize a sign-in sheet at the front desk where you will be asked to sign your namethat we will call from the waiting room when your physician becomes available.
We may use or disclose your PHI, to occasionally, contact you, to set up or confirm an appointment. Your cell phone numberat the bottom of this form would be helpful in this regard.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: thoseRequired by Law, Public Health issues, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements,Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donation, if applicable, Research data, Criminal Activity, MilitaryActivity and National Security, Workers’ Compensation, Inmates and required uses and disclosures to the Department of Health and HumanServices, that oversee HIPAA compliance of our office.
Other Permitted and Required Uses and Disclosures
will be made only with your consent, authorization or opportunity to objectunless 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.
You may send us a request in writing to see or have a copy of your information we have on file,
unless otherwiserestricted by law. You may notify us of any incomplete or inaccurate personal information that your wish amended. Wereserve the right to disagree with your changes. In the event of a disagreement, we will provide you with information aboutour denial of your changes and the means with which you may appeal it.•
You have the right to request additional restrictions on how we may use, and to whom we may disclose your PHI.
However, we are not legally required to agree to your request, in particular, instances where it may be prohibited by law or not in your best interest. Your request must be specific and include to whom you want the restriction to apply.•
You may request us to use reasonable alternative means of contacting you
regarding health matters such as by cell phone or e-mail or direct us to an alternate address when appropriate.•
You may request an accounting of any disclosures concerning your PHI,
except when these are made for treatment, payment or health care operations, or the law otherwise restricts the accounting.•
You have the right to a copy of this notice upon request.Additional Information
: We are required by law to maintain the privacy of, and provide individuals with, this notice of our legalduties and privacy practices with respect to protected health information. If you have any objections to this form or have any questionsabout your rights to privacy or how these rights have been handled by this office, please contact our HIPAA Compliance Officer in person or by phone at (734)-671-1740.
Your signature below acknowledges that you have received this Notice of Privacy Practices.
Signature________________________________________ Printed Name____________________________________ Cell Phone
number where we can leave a message:
__________________ E-mail address ( used for this office only) ______________________________________________________________