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Privacy Practices
Download this form as a PDF.
Notice of Health Information Practices of Chan Chiropractic Centers
In accordance with the Health Insurance Portability and Accountability Act (HIPAA) of 2003, this notice describes how
information about you may be used and disclosed and how you can get access to this information at the Chan Chiropractic
Centers. Please review it carefully.
Understanding Your Health Record/Information
Every time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically this record
contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This
information, often referred to as your health or medical record, serves as a:
- Basis for planning your care and treatment among health care providers
- Legal document describing the care you received
- Means by which you or a third party payer can verify that services billed were actually provided
- A tool in educating health professionals such as in medical research
- A source of information for public health officials charged with improving the health of the nation
- A source of data for facility planning, marketing, and improvement of care.
Your Health Information Rights
Although your health record is the physical property of the healthcare practitioner or facility that compiled it the information
belongs to you. You have the right to:
- Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522
- Obtain a paper copy of the notice of information practices upon request
- Inspect and copy your health record as provided for in 45 CFR 164.524 for an administrative fee of $35.
- Amend your health record as provided in 45 CFR 164.528. We require the request be made in writing, explaining why
the information should be amended. Your request may be denied under circumstances.
- Obtain an account of disclosures of your health information as provided in 45 CFR 164.528 for up to 6 years prior to the
date of your request but not prior to April 14th, 2003. Your request must be made in writing to our Privacy Officer. This
accounting does not include disclosures made to carry out treatment, payment and health care operations, disclosures
made to you, disclosures to individuals involved with your care, disclosures made for national security or intelligence
purposes, and disclosures made prior to the compliance date of the HIPAA Privacy Rule.
- Request communications of your health information by alternative means or at alternative locations.
- Revoke your authorization to use or disclose health information except to the extent that action has already been taken.
Our Responsibilities
We at Chan Chiropractic are required to:
- Maintain the privacy of your health information.
- Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain
about you.
- Abide by the terms of this notice.
- Notify you if we are unable to agree to a requested restriction you have made.
- Accommodate reasonable requests you may have to communicate health information by alternative means or by
alternative locations.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we
maintain. Should our information practices change, we will mail you a revised notice to the address you’ve supplied us.
We will not use or disclose your health information without your authorization, except as described in this notice. Any
additional authorizations must be written and signed by you or parent/legal guardian for a minor in the presence of the staff
of Chan Chiropractic.
For More Information or to Report a Problem
If you have questions and would like additional information, you may contact the Privacy Officer at Chan Chiropractic at
858-484-0800.
If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer or with the U.S.
Department of Health and Human Services. There will be no retaliation for filing a complaint.
Examples of Disclosures for Treatment, Payment and Health Operations
- We will use your health information for treatment. For example: Information obtained by our team of health care
providers will be recorded and used within the team to determine the course of treatment that best suits your needs.
- We will use your health information for payment. For example: A bill may be sent to you or a third party payer. The
information on or accompanying the bill may include information that identifies you, as well as your diagnosis,
procedures and supplies used.
- We will use your health information for regular health operations. For example: Members of your healthcare team may
use your health record to assess the care and outcomes in your case and others like it. This information will then be
used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.
Other Uses and Disclosures
- Business Associates: There are some services provide in our organization through contacts with business associates.
Examples include physician services with radiologists, diagnostic imaging Centers, laboratory test centers, and other
specialists. When these services are contracted, we may disclose your health information to our business associates so
that they can perform the job we’ve asked them to do and bill you or your third party payer for services rendered. So
that your health information is protected, however, we require the business associates to appropriately safeguard your
information.
- Law Enforcement/Judicial and Administrative Proceedings: We may disclose protected health information in a judicial
or administrative proceeding if the request for the information is through an order from a court or administrative tribunal.
Such information may also be disclosed in response to a subpoena or other lawful process if certain assurances regarding
notice to the individual or a protective order are provided.
- Notification: In cases of emergency, we may use or disclose information to notify or assist in notifying a family
member, personal representative, or person responsible for your care, your location and general condition. In nonemergency
situations, however, we will not disclose your information to others, not even family members. If you are a
minor, however, by law we may disclose your health information to your legal guardian or parent.
- Research: We may disclose information to researchers when their research has been approved by an Institutional review
Board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
- Marketing: We may contact you to provide appointment reminders or information about treatment alternatives or other
health related benefits and services that may be of interest and benefit to you. They may be left on voicemail, postcards,
or letters.
- Clinic Displays: We may post, for example, thank you letters on our clinic bulletin board.
- Victims of Abuse, Neglect or Domestic Violence: We reserve the right, by law, to disclose protected health information
to appropriate government authorities regarding victims of abuse, neglect, or domestic violence.
- Funeral Directors: We may disclose health information to funeral directors consistent with applicable law to carry out
their duties.
- Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ
procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the
purpose of tissue donation and transplant.
- Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with
respect to food, supplements, product and product defects or post marketing surveillance information to enable product
recalls, repairs or replacements.
- Worker’s Compensation: We may disclose health information to the extent authorized by and to the extent necessary to
comply with laws relating to worker’s compensation or other similar programs established by law.
- Public Health: As required by law, we may disclose your health information to public health or legal authorities
responsible for preventing and controlling disease, injury, or disability.
- Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution and its
agents, health information necessary for your health, and the health and safety of other individuals.
My signature below indicates that I have been provided with a copy of the notice of privacy practices and I have read,
understood, and agreed to the privacy policies of Chan Chiropractic Center.
_______________________________________ _____________________
Patient Signature Date
_______________________________________ _____________________
Signature of Parent/Legal Guardian Date
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