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.
This Chiropractic Practice ( “Mid-Ohio Chiropractic, Inc.” ), in
accordance with the federal Privacy Rule, 45 CFR parts 160 and 164
(the “Privacy Rule”) and applicable state law, is committed to
maintaining the privacy of your protected health information
("PHI"). PHI includes information about your health condition and
the care and treatment you receive from the Practice and is often
referred to as your health care or medical record. This Notice
explains how your PHI may be used and disclosed to third parties.
This Notice also details your rights regarding your PHI.
HOW THE PRACTICE MAY USE AND
DISCLOSURE YOUR PROTECTED HEALTH INFORMATION
The Practice, in accordance with this Notice and without asking for
your express consent or authorization may use and disclose your PHI
for the purposes of:
Treatment – To provide you with the health care you require,
the Practice may use and disclose your PHI to those health care
professionals, whether on the Practice's staff or not, so that it
may provide, coordinate, plan and manage your health care. For
example, a chiropractor treating you for lower back pain may need to
know and obtain the results of your latest physician examination or
last treatment plan.
Payment – To get paid for services provided to you, the
Practice may provide your PHI, directly or through a billing
service, to a third party who may be responsible for your care,
including insurance companies and health plans. If necessary, the
Practice may use your PHI in other collection efforts with respect
to all persons who may be liable to the Practice for bills related
to your care. 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
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.
Health Care Operations – To operate in accordance with
applicable law and insurance requirements, and to provide quality
and efficient care, the Practice may need to compile, use and
disclose your PHI. For example, the Practice may use your PHI to
evaluate the performance of the Practice's personnel in providing
care to you.
OTHER EXAMPLES OF HOW THE PRACTICE MAY USE YOUR
PROTECTED HEALTH INFORMATION
(a) Advice of Appointment and Services. – The
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 may be 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.
(b) Directory/Sign-In Log. – The Practice maintains a sign-in log at
its reception desk for individuals seeking care and treatment in the
office. The sign-in log is 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. This
information may be seen by, and is accessible to, others who are
seeking care or services in the Practice’s offices.
(c) Family/Friends. – The Practice may disclose to a 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. 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. However, in
both cases, the following conditions will apply:
If you are present at or prior to the use or disclosure of your PHI,
the 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.
If you are not present, the 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.
Other Use & Disclosures WHICH MAY BE PERMITTED OR REQUIRED BY LAW
The Practice may also use and disclose your PHI, without your
consent or authorization in the following instances:
De-identified Information – The Practice may use and disclose health
information that may be related to your care but does not identify
you and cannot be used to identify you.
Business Associate – The Practice may use and disclose PHI to one or
more of its business associates if the Practice obtains satisfactory
written assurance, in accordance with applicable law, that the
business associate will appropriately safeguard your PHI. 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.
Personal Representative – The Practice may use and disclose PHI: a
person who, under applicable law, has the authority to represent you
in making decisions related to your health care.
Emergency Situations – The Practice may use and disclose PHI: for
the purpose of obtaining or rendering emergency treatment to you
provided that the Practice attempts to obtain your Consent as soon
as possible; or to a public or private entity authorized by law or
by its charter to assist in disaster relief efforts, for the purpose
of coordinating your care with such entities in an emergency
situation.
Public Health Activities – The Practice may use and disclose PHI
when required by law to provide information to a public health
authority to prevent or control disease.
Abuse, Neglect or Domestic Violence – The Practice may use and
disclose PHI when authorized by law to provide information if it
believes that the disclosure is necessary to prevent serious harm.
Health Oversight Activities – The Practice may use and disclose PHI
when required by law to provide information in criminal
investigations, disciplinary actions, or other activities relating
to the community's health care system.
Judicial and Administrative Proceeding - The Practice may use and
disclose PHI in response to a court order or a lawfully issued
subpoena.
Law Enforcement Purposes - The Practice may use and disclose PHI,
when authorized, to a law enforcement official. For example, your
PHI may be the subject of a grand jury subpoena, or if the Practice
believes that your death was the result of criminal conduct.
Coroner or Medical Examiner - The Practice may use and disclose PHI
to a coroner or medical examiner for the purpose of identifying you
or determining your cause of death.
Organ, Eye or Tissue Donation - The Practice may use and disclose
PHI if you are an organ donor, to the entity to whom you have agreed
to donate your organs.
Research - The Practice may use and disclose PHI subject to
applicable legal requirements if the Practice is involved in
research activities.
Avert a Threat to Health or Safety - The Practice may use and
disclose PHI if it believes that such disclosure is necessary to
prevent or lessen a serious and imminent threat to the health or
safety of a person or the public and the disclosure is to an
individual who is reasonably able to prevent or lessen the threat.
Specialized Government Functions – The Practice may use and disclose
PHI when authorized by law with regard to certain military and
veteran activity.
Workers' Compensation - The Practice may use and disclose PHI if you
are involved in a Workers' Compensation claim, to an individual or
entity that is part of the Workers' Compensation system.
National Security and Intelligence Activities – The Practice may use
and disclose PHI to authorized governmental officials with necessary
intelligence information for national security activities.
Military and Veterans – The Practice may use and disclose PHI if you
are a member of the armed forces, as required by the military
command authorities.
Authorization
Uses and/or disclosures, other than those described above, will be
made only with your written Authorization.
YOUR RIGHTS
You have the right to:
Revoke any Authorization or consent you have given to the Practice,
at any time. To request a revocation, you must submit a written
request to the Practice's Privacy Officer.
Request special restrictions on certain uses and disclosures of your
PHI as authorized by law. In general, this relates to your right to
request special restrictions concerning disclosures of your PHI
regarding uses for treatment, payment and operational purposes under
Privacy Rule Section 164.522(a) and restrictions related to
disclosures to your family and other individuals involved in your
care under Section 164.510(b). Except in certain instances, the
Practice may not be obligated to agree to any requested
restrictions. 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. If the Practice agrees to
your request, the Practice will comply with your request unless the
information is needed in order to provide you with emergency
treatment.
Receive confidential communications or PHI by alternative means or
at alternative locations as provided by Privacy Rule Section
164.522(b). For instance, you may request all written communications
to you marked “Confidential Protected Health Information”. You must
make your request in writing to the Practice's Privacy Officer. The
Practice will accommodate all reasonable requests.
Inspect and copy your PHI as provided by federal law (including
Section 164.524) and state law. To inspect and copy your PHI, you
must submit a written request to the Practice's Privacy Officer. The
Practice can charge you a fee for the cost of copying, mailing or
other supplies associated with your request. 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.
Amend your PHI as provided by federal law (including Section
164.526) and state law. To request an amendment, you must submit a
written request to the Practice's Privacy Officer. You must provide
a reason that supports your request. The 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. If you disagree with the Practice's denial, you will have
the right to submit a written statement of disagreement.
Receive an accounting of disclosures of your PHI as provided by
federal law (including Privacy Rule Section 164.528) and state law.
To request an accounting, you must submit a written request to the
Practice's Privacy Officer. The request must state a time period,
which may not be longer than six (6) years and may not include dates
before April 14, 2003. The request should indicate in what form you
want the list (such as a paper or electronic copy). The first list
you request within a twelve (12) month period will be free, but the
Practice may charge you for the cost of providing additional lists.
The Practice will notify you of the costs involved and you can
decide to withdraw or modify your request before any costs are
incurred.
Receive a paper copy of this Privacy Notice from the Practice (as
provided by Privacy Rule Section 164.520(b)(1)(iv)(F)) upon request
to the Practice's Privacy Officer.
Complain to the Practice or to the Secretary of HHS (as provided by
Privacy Rule Section 164.520(b)(1)(vi)) if you believe your privacy
rights have been violated. To file a complaint with the Practice,
you must contact the Practice's Privacy Officer. All complaints must
be in writing.
To obtain more information about your privacy rights or if you have
questions you want answered about your privacy rights (as provided
by Privacy Rule Section 164.520(b)(2)(vii)), you may contact the
Practice's Privacy Officer, as follows:
Mid-Ohio Chiropractic, Inc.
Attn: Billing Dept.
714 N. Sandusky Ave.
Upper Sandusky OH 43351
IN ACCORDANCE WITH SECTION 3701.74 OF THE OHIO REVISED CODE,
YOU OR YOUR REPRESENTATIVE MAY REQUEST COPY OF YOUR MEDICAL RECORD.
A "Medical record" means data in any form that pertains to your
medical history, diagnosis, prognosis, or medical condition and that
is generated and maintained by this Practice in the process of the
your health care treatment.
We will provide medical records to your "'representative" when you
provide written authorization that your representative is authorized
to act on your behalf regarding access to your medical records.
If you or your representative wishes to examine or obtain a copy of
part or all of a medical record, you must submit a written request
signed by you and dated not more than sixty days before the date on
which it is submitted.
You or your representative who wishes to obtain a copy of the record
shall indicate in the request whether the copy is to be sent to your
residence, your medical physician or another chiropractic physician,
or representative, or held for you at our office.
Within 30 days after receiving your request, this office shall permit
you to examine the record during regular business hours without
charge or, on request, shall provide a copy of the record.
This office shall take reasonable steps to establish the identity of
the person making the request to examine or obtain a copy of your
record.
In those rare occasions when this office denies a request for you to
review your records, it will do so in compliance with applicable
state and federal laws, explaining the reason for the denial and
your rights as set forth in the Notice of Privacy Practices. You may
have a right to bring a civil action to enforce your right to access
to your records.
In accordance with Section 3701.741 of the Ohio Revised Code, this
office will charge you the following fees for accessing copies of
your records:
• An initial fee of fifteen dollars for the records search
• One dollar per page for the first ten pages
• Fifty cents per page for pages eleven through fifty
• Twenty cents per page for pages fifty-one and higher
• For data not recorded on paper, the actual cost of making the copy
• The actual cost of any related postage
Copies are provided free to:
The bureau of workers' compensation
The industrial commission
The department of job and family services
Title II or Title XVI of the "Social Security Act"
Different fees may apply per contract. This section does not apply
to copies of medical records provided to Insurers.
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