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Notice of Privacy Practices

Wiederrich Chiropractic Clinic
14103 Poway Rd., CA 92064

         This Notice is effective April 10, 2003 and will remain in effect until our practice replaces it. It is provided to you as required by federal law, under the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  The terms of this Notice apply to all records containing your protected health information (PHI) that are created or retained by our practice.

         We are required to provide this Notice to each patient beginning no later than the date of our first service delivery to the patient after April 14, 2003. We are required to make a good-faith attempt to obtain written acknowledgement of receipt of this Notice from each patient. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this Notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice to take with you at any time.

         We reserve the right to, at any time, change our privacy practices and the terms of this Notice effective for all health information that we maintain, including health information we created or received before we made the changes, provided such changes are permitted by applicable law. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available.

         This Notice describes how health information about you (as a patient of this practice) may be used and disclosed and how you can get access to your individually identifiable health information. Please review this Notice carefully. The privacy of your health information is important to us.

A.     Our Commitment to Your Privacy:

                  Our practice is dedicated to maintaining the privacy of your individually identifiable health information, as required by applicable federal and state law. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this Notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

                  We realize that these laws are complicated, but we must provide you with the following important information:  (1) how we may use and disclose your PHI, (2) your privacy rights in your PHI, and (3) our obligations concerning the use and disclosure of your PHI.

B.     We May Use and Disclose Your PHI in the Following Ways:

  1. Treatment. Our practice may use or disclose your PHI to treat you. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other healthcare providers for purposes related to your treatment.
  2. Payment. Our practice may use and disclose your PHI in order to bill and/or collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify benefit eligibility and range of benefits. We may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. In addition, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other healthcare providers and entities to assist in their billing and collection efforts.
  3. Healthcare operations. Our practice may use and disclose your PHI in order to operate our business. We may disclose your PHI to other healthcare providers and entities to assist in their healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professions, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities
  4. Appointment reminders. Our practice may use and disclose your PHI to contact you and provide you with appointment reminders (such as voicemail messages, postcards and/or letters.)
  5. Treatment options. Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives.
  6. Health-related benefits and services. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.
  7. Release of information to family/friends. Our practice may release your PHI to a friend, family member or other person to the extent necessary to help with your healthcare or payment for your healthcare, but only if you agree that we may do so.
  8. Release of information to persons involved in care. Our practice may use or disclose your PHI to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your PHI, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency situations, we will disclose PHI based on a determination using our professional judgment, disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our experience and professional judgment with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
  9. Marketing health-related services. Our practice will not use your health information for marketing communications without your written authorization.
  10. Disclosures required by law. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.

C.     Use and Disclosure of Your PHI in Certain Special Circumstances:

Public health risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:

•     Maintaining vital records, such as births and deaths,

•     Reporting child abuse, neglect, or reactions to drugs or problems with products or devices,

•     Preventing or controlling disease, injury or disability,

•     Notifying a person regarding potential exposure to a communicable disease, or regarding a potential risk for spreading or contracting a disease or condition, or if a product or device they may be using has been recalled,

•     Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or

      neglect of an adult patient (including domestic violence); however, we will only disclose this

information if the patient agrees or we are required or authorized by law to disclose this information,

•     Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

2.            Health oversight activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the healthcare system in general.

3.            Lawsuits and similar proceedings. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. Our practice must first make an effort to inform you of the request or to obtain an order protecting the information the party has requested.

         4.      Law enforcement. Our practice may release PHI if asked to do so by a law enforcement official:

•     Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement,

•     Concerning a death we believe has resulted from criminal conduct,

      •     In response to a warrant, summons, court order, subpoena or similar legal process,

•     To identify/locate a suspect, material witness, fugitive or missing person,

•     In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).

         5.      National Security.  Under certain circumstances, our practice may disclose to military authorities the PHI of Armed Forces personnel. We may disclose to authorized federal officials PHI required for lawful intelligence, counterintelligence, and other national security activities. Also under certain circumstances, our practice may disclose PHI to a correctional institution or law enforcement official having lawful custody of an inmate or patient.

         6.      Deceased patients. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.

D.     Your Rights Regarding Your PHI:

         1.      Confidential communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. You must make this request in writing and it must specify the alternative manner or location, and provide a satisfactory explanation how payment will be handled under the alternative manner or location that you request. Our practice will accommodate reasonable requests.

         2.      Requesting restrictions. You have the right to request additional restrictions in our use or disclosure of your PHI. We are not required to agree to your request; however, if we do agree, we will abide by our agreement, except when otherwise required by law, in emergencies or when the information is necessary to treat you. You must make your request in writing. Your request must describe in a clear and concise fashion:

•   The information you wish restricted,

•   Whether you are requesting to limit our practice’s use, disclosure or both,

•   To whom you want the limits to apply.

         3.      Inspection and copies. You have the right to inspect or get copies of your PHI, with limited exceptions. You may request that we provide copies in a format other than photocopies. Our practice will use the format you request, unless we cannot practicably do so. You must submit your request in writing in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed healthcare professional chosen by us will conduct reviews.

         4.      Amendment. You may ask us to amend your PHI if you believe it is incorrect or incomplete. Your request for an amendment must be made in writing and must provide us with a reason that supports your request for amendment. Our practice may deny your request under certain circumstances. 

         5.      Accounting of disclosures. Our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as part of the routine patient care in our practice is not required to be documented. In order to obtain an “accounting of disclosures,” you must submit your request in writing. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

6.            Right to a paper copy of this Notice. You are entitled to receive a paper copy of our Notice of privacy practices. You may ask us to give you a copy of this Notice at any time.

7.            Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this Notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note: we are required to retain records of your care.

E.     Questions and Complaints.

         1.      Questions. Please contact the Contact Officer listed below should you have any additional questions regarding the Notice or need additional information regarding our privacy practices.

2.            Complaints/Requests. If you believe your privacy rights have been violated, if you disagree with a decision made about access to your PHI, in response to a request you made to amend or restrict the use or disclosure of your PHI, or to have us communicate with you in alternative manners or alternative locations, you may file a complaint or request with our practice. You can do so by contacting the Contact Officer listed below. You may also submit your complaint to the U.S. Department of Health and Human Services. (Our practice will provide you with their address upon request.)  All complaints must be submitted in writing. We support the right to the privacy of your health information. You will not be penalized should you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer:    Hans O. Wiederrich
Telephone:        (858) 748-4343
Fax:             (858) 748-4881
Email:           docs@powaydc.com

14103 Poway Rd.
Poway, CA 92064

Notice of Privacy Practices:
04/14/2003 Version