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This document is to notify you of your HIPAA privacy rights.

This document DOES NOT need to be printed and is for your reference only.

HARTER SEACREST & EMERY LLP

  ATTORNEYS AND COUNSELORS

                          

GOSHORN CHIROPRACTIC & WELLNESS

         PATIENT PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.1

This Office/Practice is committed to maintaining the privacy of your protected health information ("PHI"), which includes information about your health condition and the care and treatment you receive from the Practice. The creation of a record detailing the care and services you receive helps this office to provide you with quality health care. This Notice details how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI.

•      The Office/Practice may use and/or disclose your PHI for the following purposes:

  1. Treatment - In order to provide you with the health care you require, the Office/Practice will provide your PHI to those health care professionals, whether on the Practice's staff or not, directly involved in your care so that they may understand your health condition and needs. For example, a physician treating you for lower back pain may need to know the results of your latest physician examination by this office.2
  2. Payment - In order to get paid for services provided to you, the Office/Practice will provide your PHI, directly or through a billing service, to appropriate third party payors, pursuant to their billing and payment requirements. For example, the Practice may need to provide the Medicare program with information about health care services that you received from the Practice so that the Practice can be properly reimbursed. The Practice may also need to tell your insurance plan about treatment you are going to receive so that it can determine whether or not it will cover the treatment expense.3
  3. Health Care Operations - In order for the Office/Practice to operate in accordance with applicable law and insurance requirements and in order for the Practice to continue to provide quality and efficient care, it may be necessary for the Practice to compile, use and/or disclose your PHI. For example, the Practice may use your PHI in order to evaluate the performance of the Practice's personnel in providing care to you.4

•      The Office/Practice may also use and/or disclose your PHI without your specific authorization in the following
additional instances5:

  1. De-identified Information - Information that does not identify you and, even without your name, cannot be used to identify you.6
  2. Business Associate - To a business associate if the Office/Practice obtains satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI.7 A business associate is an entity that assists the Practice in undertaking some essential function, such as a billing company that assists the office in submitting claims for payment to insurance companies or other payers.8
  3. Personal Representative - To a person who, under applicable law, has the authority to represent you in making decisions related to your health care.9
  4. Emergency Situations -for the purpose of obtaining or rendering emergency treatment to you if the opportunity for you to

object cannot be obtained due to your incapacity or emergent treatment circumstances and the treatment is consistent with your prior expressed preferences and is in your best interest10; or

 

(e) Public Health Activities - Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent or control disease.12

(g) Abuse, Neglect or Domestic Violence - To a government authority if the Office/Practice is required by law to make such disclosure. If the Practice is authorized by law to make such a disclosure, it will do so if it believes that the disclosure is necessary to prevent serious harm.13

(h) Health Oversight Activities - Such activities, which must be required by law, involve government agencies and may include, for example, criminal investigations, disciplinary actions, or general oversight activities relating to the community's health care system.14

(i) Judicial and Administrative Proceeding - For example, the Office/Practice may be required to disclose your PHI in response to a court order or a lawfully issued subpoena.15

(j) Law Enforcement Purposes - In certain instances, your PHI may have to be disclosed to a law enforcement official. For example, your PHI may be the subject of a grand jury subpoena. Or, the Practice may disclose your PHI if the Practice believes your death was the result of criminal conduct.16

(k) Coroner or Medical Examiner - The Office/Practice may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death.17

(I) Organ. Eve or Tissue Donation - If you are an organ donor, the Practice may disclose your PHI to the entity to whom you have agreed to donate your organs.18

(m) Research - If the Office/Practice is involved in research activities, your PHI may be used, but such use is subject to numerous governmental requirements intended to protect the privacy of your PHI.19

(n) Avert a Threat to Health or Safety - The Office/Practice may disclose your PHI if it believes disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and disclosure is to an individual who is reasonably able to prevent or lessen the threat.20

(o) Specialized Government Functions - This refers to disclosures of PHI that relate primarily to military and veteran activity.21

(p) Workers' Compensation - If you are involved in a Workers' Compensation claim, the Office/Practice may be required to disclose your PHI to an individual or entity that is part of the Workers' Compensation system.22

(q) National Security and Intelligence Activities — The Office/Practice may disclose your PHI in order to provide authorized governmental officials with necessary intelligence information for national security activities and purposes authorized by law.23

(r) Military and Veterans - If you are a member of the armed forces, the Office/Practice may disclose your PHI as required by the military command authorities.24

(s) Fundraising — In order to conduct or assist business associates and/or other institutionally related foundations raise funds for a charitable purpose, such as a local hospital, the American Red Cross or other private or public disaster relief agency, Breast Cancer or AIDS-related research, etc., this office/practice may give out demographic information about you as well as any dates health care was provided to you without your specific authorization.25 However, if this office/practice does engage in any fundraising activity, it must include instructions in the fundraising materials indicating how you may decline to receive any further fundraising communications from this office/practice.

APPOINTMENT REMINDER

•      The Office/Practice may, from time to time, contact you to provide appointment reminders or information
about treatment alternatives or other health-related benefits and services that may be of interest to you. The
following appointment reminders are used by the Practice: a) a postcard mailed to you at the address provided
by you; and b) telephoning your home and leaving a message on your answering machine or with the individual
answering the phone.26

      

 

•      The Office/Practice maintains a directory of and sign-in log for individuals seeking care and treatment in the
office. Directory and sign-in log are located in a position where staff can readily see who is seeking care in the
office, as well as the individual's location within the Practice's office suite.27 This information may be seen by, and
is accessible to, others who are seeking care or services in the Practice's offices.

FAMILY/FRIENDS

•      The Office/Practice may disclose to your family member, other relative, a close personal friend, or any other
person identified by you, your PHI directly relevant to such person's involvement with your care or the payment
for your care.28 The Practice may also use or disclose your PHI to notify or assist in the notification (including
identifying or locating) a family member, a personal representative, or another person responsible for your care,
of your location, general condition or death.29 However, in both cases, the following conditions will apply:

  1. If you are present at or prior to the use or disclosure of your PHI, the Office/Practice may use or disclose your PHI if you agree, or if the Practice can reasonably infer from the circumstances, based on the exercise of its professional judgment, that you do not object to the use or disclosure.30
  2. If you are not present, the Office/Practice will, in the exercise of professional judgment, determine whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is directly relevant to the person's involvement with your care.31

AUTHORIZATION

•      Uses and/or disclosures, other than those described above, will be made only with your written
Authorization.32

YOUR RIGHTS

•      You have the right to:

  1. Revoke any Authorization33 in writing, at any time. To request a revocation, you must submit a written request to the Practice's Privacy Officer.
  2. Request restrictions on certain use and/or disclosure of your PHI as provided by law.34 However, the Office/Practice is not obligated to agree to any requested restrictions.35 To request restrictions, you must submit a written request to the Practice's Privacy Officer. In your written request, you must inform the Practice of what information you want to limit, whether you want to limit the Practice's use or disclosure, or both, and to whom you want the limits to apply.36 If the Practice agrees to your request, the Practice will comply with your request37 unless the information is needed in order to provide you with emergency treatment.38
  3. Receive confidential communications or PHI by alternative means or at alternative locations. You must make your request in writing to the Practice's Privacy Officer. The Practice will accommodate all reasonable requests.39
  4. Inspect and copy your PHI as provided by law.40 To inspect and copy your PHI, you must submit a written request to the Practice's Privacy Officer.41 The Practice can charge you a fee for the cost of copying, mailing or other supplies associated with your request.42 In certain situations that are defined by law, the Practice may deny your request, but you will have the right to have the denial reviewed as set forth more fully in the written denial notice.43
  5. Amend your PHI as provided by law.44 To request an amendment, you must submit a written request to the Practice's Privacy Officer.45 You must provide a reason that supports your request.46

Practice may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by the Practice (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by the Practice, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete.47 If you disagree with the Practice's denial, you will have the right to submit a written statement of disagreement.48

(0

(g) Receive a paper copy of this Privacy Notice from the Office/Practice upon request to the Practice's Privacy Officer.54

(h) Complain to the Office/Practice55 or to the Secretary of HHS56 if you believe your privacy rights have been violated.57 To file a complaint with the Office/Practice, you must contact the Practice's Privacy Officer.58 All complaints must be in writing.59

(i) To obtain more information on, or have your questions about your rights answered, you may contact
the Practice's Privacy Officer,60_____________________ , at________________ or via email at____________________________ .

PRACTICE'S REQUIREMENTS

•    The Office/Practice:

  1. Is required by federal law to maintain the privacy of your PHI61 and to provide you with this Privacy Notice detailing the Practice's legal duties and privacy practices with respect to your PHI.62
  2. Is required by State law to maintain a higher level of confidentiality with respect to certain portions of your medical information than is provided for under federal law. In particular, the Practice is required to comply with the following State statutes:

  • NY Public Health Law, Article I, Title II, § 18 Access to patient information
  • NY Public Health Law, Article I, Title II, § 18-a. Disclosure of information

NY Public Health Law, Article 21, Control of Acute Communicable Diseases, Title I, General Provisions, § 2102. Communicable diseases; laboratory reports and records.

•      NY Public Health Law, Article 21, Control of Acute Communicable Diseases, Title III, Human
Immunodeficiency Virus

§ 2134. Disclosure of medical information

§ 2135. Confidentiality

§2136. Liability NY Public Health Law, Article 27-F, HIV and AIDS related information

§ 2780. Definitions

§2781. HIV related testing

§ 2782. Confidentiality and disclosure

§ 2783. Penalties; immunities

§ 2784. Applicability to insurance institutions and insurance support organizations

§ 2785. Court authorization for disclosure of confidential HIV related information

§ 2785-a.    Court order for HIV related testing in certain cases

§ 2786. Rules and regulations; forms; report

§ 2787. Separability New York Social Services Law

§ 413.  Persons and officials required to report cases of suspected child abuse or maltreatment

§ 414.  Any person permitted to report

 

§ 416.   Obligations of persons required to report § 417.   Taking a child into protective custody

•      § 418.  Mandatory reporting to and post-mortem investigation of deaths by medical examiner

or coroner

•      §419.   Immunity from liability

§ 420.   Penalties for failure to report New York Workers' Compensation Law, Article Seven Miscellaneous Provisions

•      § 110-a.     Confidentiality of workers' compensation records

New York Penal Law, Article 265, Firearms and other dangerous weapons

•      § 265.25     Certain wounds to be reported

§ 265.26     Burn injury and wounds to be reported New York Mental Hygiene Law (MHL) Article 33, Rights of Patients New York Social Services Law, Title 1, Protective Services

•      §473.  Protective services

New York Social Service Law, Article 9B, Title 2, Short-term Involuntary Protective Services Orders

  • § 473-b.      Reporting of endangered adults; persons in need of protective services New York Social Services Law, Title 3, Community Guardianship
  • § 473-e.     Confidentiality of protective services for adults' records New York Civil Practice Law and Rules (CPLR)

Article 23.   Subpoenas, Oaths and Affirmations

  • § 2301. Scope of subpoena
  • § 2302. Authority to issue

§ 2305. Attendance required pursuant to subpoena; possession of books, records,

documents or papers § 2306. Hospital records; medical records of department or bureau of a municipal corporation

or of the state New York Civil Practice Law and Rules, Article 31 Disclosure §3101. Scope of disclosure

  • § 3102. Method of obtaining disclosure
  • § 3103. Protective orders
  • Rule 3107. Notice of taking oral questions
  • Rule 3108. Written questions; when permitted

  • Rule 3109. Notice of taking deposition on written questions Rule 3111. Production of things at the examination
  • Rule 3118. Demand for address of party or of person who possessed and assigned cause of

action or defense

•      Rule 3120. Discovery and production of documents and things for inspection, testing,

copying or photographing §3121. Physical or mental examination

  • Rule 3122. Objection to disclosure, inspection or examination; compliance
  • § 3123. Admissions as to matters of fact, papers, documents and photographs Rule 3124. Failure to disclose; motion to compel disclosure

Rule 3125. Place where motion to compel disclosure made § 3126. Penalties for refusal to comply with order or to disclose

  • § 3130. Use of interrogatories
  • § 3131. Scope of interrogatories Rule 3132. Service of interrogatories

  • Rule 3133. Service of answers or objections to interrogatories New York Civil Practice Law and Rule, Article 45, Evidence
  • § 4504. Physician, dentist, podiatrist, chiropractor and nurse
  • Rule 4518. Business records

Rule 4532-a.     Admissibility of graphic, numerical, symbolic or pictorial representations of

medical or diagnostic tests in personal injury actions § 4548. Privileged communications; electronic communication thereof

 
  1. Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.64
  2. Will distribute any revised Privacy Notice to you prior to implementation.65
  3. Will not retaliate against you for filing a complaint.66

By signing below, I certify that I have received and reviewed this notice and all of my questions have been answered to my satisfaction in language that I can understand.

Name of Individual (Printed)

 

Signature of Individual

Signature of Legal Representative (e.g., Attorney-in-Fact, Guardian, Parent if a minor):                                 Relationship

Date Signed:

 

Witness:.

                                                                                                                                                                                                                                                                                 

References:

  1. § 164.520 Notice of privacy practices for protected health information, (b) Implementation specifications: content of notice. (1) Required elements (I) Header., Federal Register 2000 (Dec 28); 65(250): 82821. Unchanged by Final Modification. Federal Register 2002 (Aug 14); 67(157): 53271. See also: DHHS Office of Civil Rights. Standards for Privacy of Individually Identifiable Health Information (Unofficial Version) (45 CFR Parts 160 and 164) Regulation Text as amended, August 14,2002:23.
  2. § 164.520 (b)(1 )(ii)(A)., p. 82821. Unchanged by Final Modification. § 164.520 Federal Register 2002 (Aug 14); 67(157): 53271. See also: DHHS Office of Civil Rights. Standards for Privacy of Individually Identifiable Health Information (Unofficial Version) (45 CFR Parts 160 and 164) Regulation Text as amended, August 14,2002:23.
  3. W. Unchanged by Final Modification. Federal Register 2002 (Aug 14); 67(157): 53271. See also: DHHS Office of Civil Rights. Standards for Privacy of Individually Identifiable Health Information (Unofficial Version) (45 CFR Parts 160 and 164) Regulation Text as amended, August 14,2002:23.
  4. Id. Unchanged by Final Modification. Federal Register 2002 (Aug 14); 67(157): 53271. See also: DHHS Office of Civil Rights. Standards for Privacy of Individually Identifiable Health Information (Unofficial Version) (45 CFR Parts 160 and 164) Regulation Text as amended, August 14,2002:23.
  5. W. § 164.520 (b)(1)(ii)(B). Federal Register 2000 (Dec 28); 56(250): 82821. Revised by Final Modification. 12.a. and § 164.520(b)(1)(ii)(B) Federal Register 2002 (Aug 14); 67(157): 53271. See also: DHHS Office of Civil Rights. Standards for Privacy of Individually Identifiable Health Information (Unofficial Version) (45 CFR Parts 160 and 164) Regulation Text as amended, August 14,2002:23.
  6. § 164.514 Other requirements relating to uses and disclosures of protected health information, (a) Standard: de-identification of protected health information., and (b) Implementation specifications: requirements for de-identification of protected health information. Federal Register 2000 (Dec 28); 65(25): 82818-82820. See also: Final Modification. § 164.514 Federal Register 2002 (Aug 14); 67(157): 53270. See also: DHHS Office of Civil Rights. Standards for Privacy of Individually Identifiable Health Information (Unofficial Version) (45 CFR Parts 160 and 164) Regulation Text as amended, August 14,2002:20.
  7. § 164.502 (e)(2). Federal Register 2000 (Dec 28); 65(250): 82806. Unchanged by Final Modification. Federal Register 2002 (Aug 14); 67(157): 53267. See also: DHHS Office of Civil Rights. Standards for Privacy of Individually Identifiable Health Information (Unofficial Version) (45 CFR Parts 160 and 164) Regulation Text as amended, August 14,2002:9.
  8. § 160.103 Definitions: Business associate. Federal Register 2000 (Dec 28); 65(250): 82798. Unchanged by Final Modification. Federal Register 2002 (Aug 14); 67(157): 53266. See also: DHHS Office of Civil Rights. Standards for Privacy of Individually Identifiable Health Information (Unofficial Version) (45 CFR Parts 160 and 164) Regulation Text as amended, August 14,2002:1.
  9. § 164.510 Uses and disclosures requiring an opportunity for the individual to agree or object, (b) Standards: uses and disclosures for involvement in the individual's care and notification purposes. (1) Permitted uses and disclosures, (i). Federal Register 2000 (Dec 28); (65(250): 82813. Unchanged by Final Modification. Federal Register 2002 (Aug 14); 67(157): 53270. See also: DHHS Office of Civil Rights. Standards for Privacy of Individually Identifiable Health Information (Unofficial Version) (45 CFR Parts 160 and 164) Regulation Text as amended, August 14,2002:15.
  10. § 164.506 Consent for uses or disclosures to carry out treatment, payment, or health care operations, (a) Standard: Consent requirement (3)(i)(A). Federal Register 2000 (Dec 28); 65(250): 82810. See also: § 164.510 (a)(3) Emergency circumstances., p. 82813. Revised by Final Modification. § 164.506 Federal Register 2002 (Aug 14); 67(157); 53268. See also: Final Modification. § 164.510 Federal Register 2002 (Aug 14); 67(157): 53270. See also: DHHS Office of Civil Rights. Standards for Privacy of Individually Identifiable Health Information (Unofficial Version) (45 CFR Parts 160 and 164) Regulation Text as amended, August 14,2002:12-13.
  11. § 164.510 (b) Standard: uses and disclosures for involvement in the individual's care and notification purposes. (4) Use and disclosure for disaster relief purposes. Federal Reoister 2000 (Dec 28); 65(250): 82813. Unchanged by Final Modification. Federal Register 2002 (Aug 14); 67(157): 53270. See also: DHHS Office of Civil Rights. Standards for Privacy of Individually Identifiable Health Information (Unofficial Version) (45 CFR Parts 160 and 164) Regulation Text as amended, August 14,2002:15.
  12. Jd. § 164.512 (b) Standard: Uses and disclosures for public health activities. (1) Permitted disclosures. Federal Register 2000 (Dec 28); 65(250): 82813-814. Essentially unchanged by Final Modification. § 164.512 Federal Register 2002 (Aug 14); 67(157): 53270. See also: DHHS Office of Civil Rights. Standards for Privacy of Individually Identifiable Health Information (Unofficial Version) (45 CFR Parts 160 and 164) Regulation Text as amended, August 14,2002:15.
  13. Jd. § 164.512 (c)(1), (2). Federal Register 2000 (Dec 28); 65(25): 82814. Essentially unchanged by Final Modification. § 164.512 Federal Register 2002 (Aug 14); 67(157): 53270. See also: DHHS Office of Civil Rights. Standards for Privacy of Individually Identifiable Health Information (Unofficial Version) (45 CFR Parts 160 and

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