Notice of Privacy Practices  updated December 4, 2024

Table of Contents  

I. How This Medical Practice May Use or Disclose Your Health Information  II. When This Medical Practice May Not Use or Disclose Your Health Information  III. Your Health Information Rights  

A. Right to Request Special Privacy Protections  

B. Right to Request Confidential Communications  

C. Right to Inspect and Copy  

D. Right to Amend or Supplement  

E. Right to an Accounting of Disclosures  

F. Right to a Paper or Electronic Copy of this Notice  

IV. Changes to this Notice of Privacy Practices  

V. Complaints  

I. How This Medical Practice May Use or Disclose Your Health Information  

This medical practice collects health information about you and stores it in a chart [and on a  computer][and in an electronic health record/personal health record]. This is your medical  record. The medical record is the property of this medical practice, but the information in the  medical record belongs to you. The law permits us to use or disclose your health information for  the following purposes: 

A. Treatment. We use medical information about you to provide your medical  care. We disclose medical information to our employees and others who are involved in providing  the care you need. For example, we may share your medical information with other Chiropractic  or other health care providers who will provide services that we do not provide. Or we may share  this information with a pharmacist who needs it to dispense a prescription to you, or a laboratory  that performs a test. We may also disclose medical information to members of your family or  others who can help you when you are sick or injured, or after you die.  

B. Payment. We use and disclose medical information about you to obtain payment  for the services we provide. For example, we give your health plan the information it requires  before it will pay us. We may also disclose information to other health care providers to assist  them in obtaining payment for services they have provided to you.  

C. Health Care Operations. We may use and disclose medical information about you to operate this medical practice. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our  professional staff. Or we may use and disclose this information to get your health plan to  authorize services or referrals. We may also use and disclose this information as necessary for  medical reviews, legal services and audits, including fraud and abuse detection and compliance  programs and business planning and management. We may also share your medical information  with our "business associates," such as our billing service, that perform administrative services  for us. We have a written contract with each of these business associates that contains terms  requiring them and their subcontractors to protect the confidentiality and security of your protected  health information. We may also share your information with other health care providers, health  care clearinghouses or health plans that have a relationship with you, when they request this  information to help them with their quality assessment and improvement activities, their patient 

safety activities, their population-based efforts to improve health or reduce health care costs, their  protocol development, case management or care-coordination activities, their review of  competence, qualifications and performance of health care professionals, their training programs,  their accreditation, certification or licensing activities, or their health care fraud and abuse  detection and compliance efforts. [Participants in organized health care arrangements only  should add: We may also share medical information about you with the other health care  providers, health care clearinghouses and health plans that participate with us in "organized  health care arrangements" (OHCAs) for any of the OHCAs' health care operations. OHCAs  include hospitals, Chiropractic organizations, health plans, and other entities which collectively  provide health care services. A listing of the OHCAs we participate in is available from the Privacy  Official.]  

D. Appointment Reminders. We may use and disclose medical information to contact  and remind you about appointments. If you are not home, we may leave this information on your  answering machine or in a message left with the person answering the phone.] 

E. Notification and Communication With Family. We may disclose your health  information to notify or assist in notifying a family member, your personal representative or  another person responsible for your care about your location, your general condition or, unless  you had instructed us otherwise, in the event of your death. In the event of a disaster, we may  disclose information to a relief organization so that they may coordinate these notification efforts.  We may also disclose information to someone who is involved with your care or helps pay for 

your care. If you are able and available to agree or object, we will give you the opportunity to  object prior to making these disclosures, although we may disclose this information in a disaster  even over your objection if we believe it is necessary to respond to the emergency  circumstances. If you are unable or unavailable to agree or object, our health professionals will  use their best judgment in communication with your family and others.  

F. Marketing. Provided we do not receive any payment for making these  communications, we may contact you to give you information about products or services related  to your treatment, case management or care coordination, or to direct or recommend other  treatments, therapies, health care providers or settings of care that may be of interest to you. We  may similarly describe products or services provided by this practice and tell you which health  plans this practice participates in. We may also encourage you to maintain a healthy lifestyle and  get recommended tests, participate in a disease management program, provide you with small  gifts, tell you about government sponsored health programs or encourage you to purchase a  product or service when we see you, for which we may be paid. Finally, we may receive  compensation which covers our cost of reminding you to take and refill your medication, or  otherwise communicate about a drug or biologic that is currently prescribed for you. We will not  otherwise use or disclose your medical information for marketing purposes or accept any payment  for other marketing communications without your prior written authorization. The authorization will  disclose whether we receive any compensation for any marketing activity you authorize, and we  will stop any future marketing activity to the extent you revoke that authorization.  

G. Sale of Health Information. We will not sell your health information without your  prior written authorization. The authorization will disclose that we will receive compensation for  your health information if you authorize us to sell it, and we will stop any future sales of your  information to the extent that you revoke that authorization.  

H. Required by Law. As required by law, we will use and disclose your health  information, but we will limit our use or disclosure to the relevant requirements of the law. When  the law requires us to report abuse, neglect or domestic violence, or respond to judicial or  administrative proceedings, or to law enforcement officials, we will further comply with the  requirement set forth below concerning those activities.  

I. Public Health. We may, and are sometimes required by law, to disclose your  health information to public health authorities for purposes related to: preventing or controlling  disease, injury or disability; reporting child, elder or dependent adult 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. When we report suspected  elder or dependent adult abuse or domestic violence, we will inform you or your personal  representative promptly unless in our best professional judgment, we believe the notification  would place you at risk of serious harm or would require informing a personal representative we  believe is responsible for the abuse or harm.  

J. Health Oversight Activities. We may, and are sometimes required by law, to disclose your health information to health oversight agencies during the course of audits, 

investigations, inspections, licensure and other proceedings, subject to the limitations imposed  by law.  

K. Judicial and Administrative Proceedings. We may, and are sometimes required  by law, to disclose your health information in the course of any administrative or judicial  proceeding to the extent expressly authorized by a court or administrative order. We may also  disclose information about you in response to a subpoena, discovery request or other lawful  process if reasonable efforts have been made to notify you of the request and you have not  objected, or if your objections have been resolved by a court or administrative order.  

L. Law Enforcement. We may, and are sometimes required by law, to 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, warrant, grand  jury subpoena and other law enforcement purposes.  

M. Coroners. We may, and are often required by law, to disclose your health  information to coroners in connection with their investigations of deaths.  

N. Public Safety. We may, and are sometimes required by law, 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 the general public.  

O. Proof of Immunization. We will disclose proof of immunization to a school that is required to have it before admitting a student where you have agreed to the disclosure on behalf  of yourself or your dependent.  

P. Specialized Government Functions. We may disclose your health information for  military or national security purposes or to correctional institutions or law enforcement officers that  have you in their lawful custody.  

Q. Workers’ Compensation. We may disclose your health information as necessary  to comply with workers’ compensation laws. For example, to the extent your care is covered by  workers' compensation, we will make periodic reports to your employer about your condition. We  are also required by law to report cases of occupational injury or occupational illness to the  employer or workers' compensation insurer.  

R. Change of Ownership. In the event that this medical practice is sold or merged  with another organization, your health information/record will become the property of the new  owner, although you will maintain the right to request that copies of your health information be  transferred to another Chiropractic or medical group.  

S. Breach Notification. In the case of a breach of unsecured protected health  information, we will notify you as required by law. If you have provided us with a current e-mail  address, we may use e-mail to communicate information related to the breach. In some  circumstances our business associate may provide the notification. We may also provide  notification by other methods as appropriate. [Note: Only use e-mail notification if you are certain  it will not contain PHI and it will not disclose inappropriate information. For example if your e-mail  address is "digestivediseaseassociates.com" an e-mail sent with this address could, if  intercepted, identify the patient and their condition.] 

II. When This Medical Practice May Not Use or Disclose Your Health Information 

Except as described in this Notice of Privacy Practices, this medical practice will, consistent with  its legal obligations, not use or disclose health information which identifies you without your  written authorization. If you do authorize this medical practice to use or disclose your health  information for another purpose, you may revoke your authorization in writing at any time.  

III. Your Health Information Rights  

A. Right to Request Special Privacy Protections. You have the right to request  restrictions on certain uses and disclosures of your health information by a written request  specifying what information you want to limit, and what limitations on our use or disclosure of that  information you wish to have imposed. If you tell us not to disclose information to your commercial  health plan concerning health care items or services for which you paid for in full out-of-pocket,  we will abide by your request, unless we must disclose the information for treatment or legal  reasons. We reserve the right to accept or reject any other request, and will notify you of our  decision.  

B. Right to Request Confidential Communications. You have the right to request that  you receive your health information in a specific way or at a specific location. For example, you  may ask that we send information to a particular e-mail account or to your work address. We will  comply with all reasonable requests submitted in writing which specify how or where you wish to  receive these communications.  

C. Right to Inspect and Copy. You have the right to inspect and copy your health  information, with limited exceptions. To access your medical information, you must submit a  written request detailing what information you want access to, whether you want to inspect it or  get a copy of it, and if you want a copy, your preferred form and format. We will provide copies  in your requested form and format if it is readily producible, or we will provide you with an  alternative format you find acceptable, or if we can’t agree and we maintain the record in an  electronic format, your choice of a readable electronic or hardcopy format. We will also send a  copy to any other person you designate in writing. We will charge a reasonable fee which covers  our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost of  preparing an explanation or summary. We may deny your request under limited circumstances. If  we deny your request to access your child's records or the records of an incapacitated adult you  are representing because we believe allowing access would be reasonably likely to cause  substantial harm to the patient, you will have a right to appeal our decision. If we deny your  request to access your psychotherapy notes, you will have the right to have them transferred to  another mental health professional.  

D. Right to Amend or Supplement. You have a right to request that we amend your  health information that you believe is incorrect or incomplete. You must make a request to amend  in writing, and include the reasons you believe the information is inaccurate or incomplete. We  are not required to change your health information, and will provide you with information about  this medical practice's denial and how you can disagree with the denial. We may deny your  request if we do not have the information, if we did not create the information (unless the person  or entity that created the information is no longer available to make the amendment), if you would  not be permitted to inspect or copy the information at issue, or if the information is accurate and  complete as is. If we deny your request, you may submit a written statement of your disagreement  with that decision, and we may, in turn, prepare a written rebuttal. All information related to any 

request to amend will be maintained and disclosed in conjunction with any subsequent disclosure  of the disputed information.  

E. Right to an Accounting of Disclosures. You have a right to receive an accounting  of disclosures of your health information made by this medical practice for six (6) years prior to  the date of the request, except that this medical practice does not have to account for the  disclosures provided to you or pursuant to your written authorization, or as described in  paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6 (notification and  communication with family) and 18 (specialized government functions) of Section A of this Notice  of Privacy Practices or disclosures for purposes of research or public health which exclude direct  patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized  by law, or the disclosures to a health oversight agency or law enforcement official to the extent  this medical practice has received notice from that agency or official that providing this accounting  would be reasonably likely to impede their activities.  

F. Right to a Paper or Electronic Copy of this Notice. You have a right to notice of  our legal duties and privacy practices with respect to your health information, including a right to  a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt  by e-mail.  

If you would like to have a more detailed explanation of these rights or if you would like to  exercise one or more of these rights, contact our Privacy Officer listed at the top of this Notice of  Privacy Practices.  

IV. Changes to this Notice of Privacy Practices  

We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until  such amendment is made, we are required by law to comply with the terms of this Notice  currently in effect. After an amendment is made, the revised Notice of Privacy Protections will  apply to all protected health information that we maintain, regardless of when it was created or  received. We will keep a copy of the current notice posted in our reception area, and a copy will  be available at each appointment and upon request. We will also post the current notice on our  website.  

V. Complaints  

Complaints about this Notice of Privacy Practices or how this medical practice handles your  health information should be directed to our Privacy Officer listed at the top of this Notice of  Privacy Practices.  

If you are not satisfied with the manner in which this office handles a complaint, you may submit  a formal complaint to:  

Centralized Case Management Operations, U.S. DHHS  

 200 Independence Avenue, S.W.  

 Room 509F HHH Bldg.  

 Washington, D.C. 20201  

 Voice Phone: (800) 368-1019 Fax: (202) 619-3818   Email: OCRMail@hhs.gov TDD: (800) 537-7697 

The complaint form may be found at:  

https://www.hhs.gov/sites/default/files/on%20line%20version%20as%20of%204- 2-19%20hip-complaint-form-10-31-19.pdf  

You will not be penalized in any way for filing a complaint.