THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
By law, we are required to provide you with our Notice of Privacy Practices (NPP).
This notice describes how your medical information may be used and disclosed by us. It also tells you how you can obtain access to this information.
As a patient you have the following rights:
1. The right to inspect and copy you information
2. The right to request corrections to your information
3. The right to request your information be restricted
4. The right to a report of disclosures of your information
5. The right to a paper copy of this Notice
The terms of the Privacy Practices apply to Elite Sports Chiropractic LLC (ESC) operating as a clinically integrated healthcare establishment. The physicians and other licensed professionals seeing and treating patients will share Protected Health Information (PHI) of our patients as necessary to carry out treatment, payment, and healthcare operations as permitted by law. We do not sell or rent to anyone the PHI you have entrusted to us.
Elite Sports Chiropractic LLC is required by the privacy regulations issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to maintain the privacy of patients’ protected health information and to provide patients with notice of ESC legal duties and privacy practices with respect to your PHI. ESC is required to abide by the terms of this Notice so long as it remains in effect. ESC reserves the right to change the terms of this Notice of Privacy Practices as necessary and make the new NPP effective for all PHI maintained by ESC. You may receive a copy of any revised notices at the
location listed above.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
Your Authorization. Except as outlined below, ESC will not use or disclose your PHI for any purpose unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing unless ESC has acted in reliance on the authorization.
Uses and Disclosures for Treatment. Elite Sports Chiropractic LLC will make uses and disclosures of your PHI as necessary for your treatment. ESC may also release your PHI to another healthcare facility or professional who is not affiliated with this organization but who is or will be providing treatment to you.
Uses and Disclosures for Payment. ESC will make uses and disclosures of you PHI as necessary for the payment of those health professionals and facilities that have treated you or provided services to you. For example, we may use information regarding your medical procedures and treatment to process and pay claims. We use the services of a clearing house to electronically submit all claims to insurance companies. When we hire or conduct business with third parties like this, we require them to protect you PHI to our standards, and snot share your information for any purpose other than the work they are doing on our behalf or as required by law.
Credit Card Information. We are required by law to take all required security and privacy measures to keep your credit information safe. All information is encrypted and follow compliance guidelines with our Processor and Billing Software with PCI DSS, HIPAA and Internet Security.
Uses and Disclosures for Health Care Operations – We may use and disclose your PHI as necessary for our health care operations. Examples of health care operations include activities relating to compliance, auditing, rating, business management, quality improvement and assurance.
Family and Friends Involved in Your Care – If you are available and do not object, we may disclose your PHI to your family, friends, and others who are involved in your care or payment of a claim. If you are unavailable or incapacitated and we determine that a limited disclosure is in your best interest, we may share limited PHI with such individuals. For example, we may use our professional judgment to disclose PHI to your spouse concerning the processing of a claim.
Appointment Reminders. We may call, text, or email to remind you of scheduled appointments, or that it is time to make an appointment. We may also call, text or email you to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post care, and/ or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.
Collections. ESC shall have the authority to charge and assess collection costs and expenses, including reasonable attorneys’ fees, and penalties and interest for the late payment or non-payment thereof. We may also text, call or email you attempts to notify or collect payments due or money owed. Unless you tell us otherwise, we will leave you a message on your home answering machine or with someone who answers your phone if you are not home. Unless you tell us otherwise, we will contact you at your work phone or nearest relative and will leave you a message on your home answering machine or with someone who answers your phone, if you are not home in attempts to collect or notify you of payments due or money owed.
Other Uses and Disclosures – We may make certain other uses and disclosures of your PHI without your authorization.
• We may use or disclose your PHI for any purpose required by law. For example, we may be required by law to use or disclose your PHI to respond to a court order.
• We may disclose your PHI for public health activities, such as reporting of disease, injury, birth and death, and for public health investigations
• We may disclose your PHI to the proper authorities if we suspect child abuse or neglect; we may also disclose your PHI if we believe you to be a victim of abuse, neglect, or domestic violence.
• We may disclose your PHI if authorized by law to a government oversight agency (e.g., a state insurance department) conducting audits, investigations, or civil or criminal proceedings.
• We may disclose your PHI in the course of a judicial or administrative proceeding (e.g., to respond to a subpoena or discovery request).
• We may disclose your PHI to the proper authorities for law enforcement purposes.
• We may disclose your PHI to coroners, medical examiners, and/or funeral directors consistent with law.
• We may use or disclose your PHI for cadaveric organ, eye or tissue donation.
• We may use or disclose your PHI for research purposes, but only as permitted by law.
• We may use or disclose PHI to avert a serious threat to health or safety.
• We may use or disclose your PHI if you are a member of the military as required by armed forces services, and we may also disclose your PHI for other specialized government functions such as national security or intelligence activities.
• We may disclose your PHI to workers' compensation agencies for your workers' compensation benefit determination.
• We will, if required by law, release your PHI to the Secretary of the Department of Health and Human Services for enforcement of HIPAA.
In the event applicable law, other than HIPAA, prohibits or materially limits our uses and disclosures of Protected Health Information, as described above, we will restrict our uses or disclosure of your Protected Health Information in accordance with the more stringent standard.
RIGHTS THAT YOU HAVE
Access to Your PHI – You have the right of access to copy and/or inspect your PHI that we maintain in designated record sets. Certain requests for access to your PHI must be in writing, must state that you want access to your PHI and must be signed by you or your representative (e.g., requests for medical records provided to us directly from your health care provider). Access request forms are available from [Insert company name] at the address below. We may charge you a fee for copying and postage.
Amendments to Your PHI – You have the right to request that PHI that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. To be considered, your amendment request must be in writing, must be signed by you or your representative, and must state the reasons for the amendment/correction request. Amendment request forms are available from us at the address below.
Accounting for Disclosures of Your PHI – You have the right to receive an accounting of certain disclosures made by us of your PHI. Examples of disclosures that we are required to account for include those to state insurance departments, pursuant to valid legal process, or for law enforcement purposes. To be considered, your accounting requests must be in writing and signed by you or your representative. Accounting request forms are available from us at the address below. The first accounting in any 12-month period is free; however, we may charge you a fee for each subsequent accounting you request within the same 12-month period.
Restrictions on Use and Disclosure of Your PHI – You have the right to request restrictions on certain of our uses and disclosures of your PHI for insurance payment or health care operations, disclosures made to persons involved in your care, and disclosures for disaster relief purposes. For example, you may request that we not disclose your PHI to your spouse. Your request must describe in detail the restriction you are requesting. We are not required to agree to your request but will attempt to accommodate reasonable requests when appropriate. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to restriction. You may make a request for a restriction (or termination of an existing restriction) by contacting us at the telephone number or address below.
Request for Confidential Communications – You have the right to request that communications regarding your PHI be made by alternative means or at alternative locations. For example, you may request that messages not be left on voice mail or sent to a particular address. We are required to accommodate reasonable requests if you inform us that disclosure of all or part of your information could place you in danger. Requests for confidential communications must be in writing, signed by you or your representative, and sent to us at the address below.
Right to a Copy of the Notice – You have the right to a paper copy of this Notice upon request by contacting us at the telephone number or address below.
Complaints – If you believe your privacy rights have been violated, you can file a complaint with us in writing at the address below. You may also file a complaint in writing with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C., within 180 days of a violation of your rights. There will be no retaliation for filing a complaint.
FOR FURTHER INFORMATION
If you have questions or need further assistance regarding this Notice, you may contact Elite Sports Chiropractic LLC’s Privacy Office by writing to: Elite Sports Chiropractic LLC Attn: Privacy Office, 1443 N Ridge Rd Suite B Wichita, KS 67212 (316) 337-5757.
This Notice is effective January 1, 2017.