EFFECTIVE DATE of this latest revision: 01/01/2017
PLEASE REVIEW THIS NOTICE CAREFULLY.
Dr. Lou Koff, D.C., d/b/a Koff Chiropractic Clinic is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about your health conditions and the care and treatment you receive from us. The creation of a record detailing the care and the services you receive helps this clinic to provide you with quality care. This Privacy Notice details how your PHI may be used and disclosed to third parties and also details your rights regarding your PHI.
Disclosure for Treatment, Payment, and Operations Purposes:
Koff Chiropractic Clinic may use and/or disclose your PHI for the purposes of:
(A) Treatment – In order to provide you with the health care you require, Koff Chiropractic Clinic will provide your PHI to those health care professionals, whether on Koff Chiropractic Clinic’s staff or not, directly involved in your care so that they may understand your health care condition and needs. For example, another physician treating you for any specific condition by need to know the results of your latest physician examination by this office.
(B) Payment – In order to get paid for services provided to you, Koff Chiropractic Clinic will provide your PHI, directly or through a billing service, to appropriate third party payers, pursuant to their billing and payment requirements. For Example, Koff Chiropractic Clinic may need to provide your insurance program with information about health care services that you received in this clinic so that we can be properly reimbursed. Koff Chiropractic Clinic may also need to tell your insurance plan about treatment you will receive so that it can determine whether or not it will cover the treatment expense.
(C) Health Care Operations – In order for the practice to operate in accordance with applicable law and insurance requirements and in order for Koff Chiropractic Clinic to continue to provide quality and efficient care, it may be necessary for us to compile, use, and/or disclose your PHI. For example, Koff Chiropractic Clinic may use your PHI in order to evaluate the performance of the practice’s personnel in providing care to you.
NO CONSENT REQUIRED
Koff Chiropractic Clinic may use and/or disclose your PHI without a written consent from you in the following instances:
(A) De-Identification Information – Information that does not identify you and, even without your name, cannot be used to identify you.
(B) Business Associate – To a business associate if Koff Chiropractic Clinic 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 us in undertaking some essential function, such as a billing company that assist the office in submitting claims for payment to insurance companies or other payers.
(C) Personal Representative – To a person who, under applicable law, has the authority to represent you, making decisions related to your health care.
(D) Emergency Situations –
(I) for obtaining or rendering emergency treatment to you provided that we attempt to obtain your consent as soon as possible; or
(II) to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for coordinating your care with such entities in an emergency situation.
(E) Communication Barriers – If, due to substantial communication barriers or inability to communicate, we have been unable to obtain your consent and we determine, in the exercise of our professional judgment, that your consent to receive treatment is clearly inferred from the circumstances.
(F) Public Health Activities – Such activities include for example, information collected by public health authority, as authorized by law, to prevent control of disease.
(G) Abuse, Neglect, or Domestic Violence – To a government authority if Koff Chiropractic Clinic is required by law to make such disclosure. If Koff Chiropractic Clinic is authorized by law to make such a disclosure, it will do so if we believe that the disclosure is necessary to prevent serious harm.
(H) Health Oversight Activities – Such activities, which must be required by law, involved government agencies and may include, for example, criminal investigations, disciplinary actions, or general oversight activities relating to the community’s health care system.
(I) Judicial and Administrative Proceedings – For example, Koff Chiropractic Clinic may be required to disclose your PHI in response to a court order or lawfully issued subpoena.
(J) Law Enforcement Purposes – In certain instances, your PHI may have to be disclosed to law enforcement official. For example, your PHI may be the subject of a grand jury subpoena. Or, we may disclose your PHI if we believe that your death was the result of criminal conduct.
(K) Coroner or Medical Examiner – Koff Chiropractic Clinic may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death.
(L) Research – If Koff Chiropractic Clinic 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.
(M) Avert a Threat to Health or Safety – Koff Chiropractic Clinic may disclose your PHI if we believe that such a disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of person or the public and the disclosure is to an individual who is reasonably able to prevent or lessen the threat.
(N) Specialized Government Functions – This refers to disclosures of PHI that relate primarily to military and veteran activity.
(O) Workers Compensation – If you are involved in a Workers’ Compensation claim, Koff Chiropractic Clinic may be required to disclose your PHI to an individual or entity that is part of Workers’ Compensation system
(P) National Security and Intelligence Activities – Koff Chiropractic Clinic may disclose your PHI in order to provide authorized governmental officials with necessary intelligence information for national security activities and purposes by law.
(Q) Military and Veterans – If you are a member of the armed forces, Koff Chiropractic Clinic may disclose your PHI as required by the military command authorities.
Koff Chiropractic Clinic may, from time to time, contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you. Koff Chiropractic Clinic may call you by telephone as an appointment reminder, or leave a message on your answering machine or with the individual answering the phone. Koff Chiropractic Clinic may also send you birthday cards or information pertinent to your condition, new research, or treatment options to the address provided by you for that purpose.
ACTIVE FILES AND RADIOGRAPHS
Koff Chiropractic Clinic maintains a file of your current radiograph (x-ray) to be used during regular active care visits. The file is located in a position where individual patients can readily see who is seeking care in the office, as well as the individual’s location with Koff Chiropractic Clinic’s suite. This information may be seen by and is accessible to, others who are seeking care or services in Koff Chiropractic Clinic. The radiographs will be displayed on regular visits in open to provide the highest quality of service at and maintain an efficient visit.
PATIENT DAILY RECORDS ACTIVE FILES (Travel Cards)
Koff Chiropractic Clinic maintains a file of your current and recent treatment to be used during regular active care visits. The file is located in a position where individual patients can see who is seeking care in the office, as well as the individuals location with Koff Chiropractic Clinic’s suite. This information may be seen by and is accessible to, others who are seeking care or services of Koff Chiropractic Clinic.
Koff Chiropractic Clinic 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 Koff Chiropractic Clinic’s suite. This information may be seen by, and is accessible to others who are seeking care or services in Koff Chiropractic Clinic.
Koff Chiropractic Clinic maintains a file of testimonials/success stories. Due to the amazing results that chiropractic care produces we share your success stories to motivate those who have not yet achieved their desired results. The public display of your testimonial/success stories is 100% optional but requested. The display/file is located in a position where individual patients are encouraged to see who is achieving results or seeking care in the office, as well as the individual’s location with Koff Chiropractic Clinic suite. This information may be seen by and is accessible to, others who are seeking care or services in Koff Chiropractic Clinic. Additinally, testimonials may be displayed on our website http://koffchiropractic.com
Koff Chiropractic Clinic 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 a person’s involvement with your care or the payment for your care. We may also use or disclose your PHI to notify or assist in the notification (including 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:
(A) If you are present at or prior to the use or disclosure of your PHI, we may use or disclose your PHI if you agree, or if we can reasonably infer from the circumstances, based on the exercise of professional judgment, that you do not object to the use or disclosure.
(B) If you are not present, we 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.
Uses and/or disclosures, other than those described above will be made only with your written Authorization.
YOUR RIGHTS: You have the right to:
(A) Revoke any authorization and/or consent, in writing, at any time. To request a revocation, you must submit a written request to Dr. Lou Koff, D.C., (privacy Officer from Koff Chiropractic Clinic) or to any of Koff Chiropractic Clinic’s staff members, or
(B) Request restrictions on certain use and/or disclosure of your PHI as provided by law. However, Koff Chiropractic Clinic is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to any staff member. In your written request, you must inform Koff Chiropractic Clinic of what information you want to limit, whether you want Koff Chiropractic Clinic’s use or disclosure, or both, and to whom you want the limits to apply. If Koff Chiropractic Clinic agrees to your request, we will comply with your request unless the information is needed in order to provide you with emergency treatment.
(C) Receive confidential communications or PHI by alternative means or at alternative locations. You must make your request in writing to Dr. Koff, or any of Koff Chiropractic Clinic’s staff members. Koff Chiropractic Clinic will accommodate all reasonable requests.
(D) Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you must submit a written request to Dr. Koff or any of the Koff Chiropractic Clinic’s staff members. Koff Chiropractic Clinic 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), Koff Chiropractic Clinic may deny your request, but you will have the right to have the denial reviewed as set forth more fully in the written notice.
(E) Amend your PHI as provided by law. To request an amendment, you must submit a written request to Dr. Koff. You must provide a reason that supports your request. Koff Chiropractic Clinic may deny your request if it is not in writing, if you do not provide a reason that supports your request, Koff Chiropractic Clinic may deny your request if it is not in writing, if you do not provide a reason that supports your request, if the information to be amended was not created by Koff Chiropractic Clinic (unless the individual or entity that created the information is no longer available). If the information is not part of your PHI maintained by Koff Chiropractic Clinic, 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 you will have the right to submit a written statement of disagreement.
(F) Receive an accounting of disclosures of your PHI as provided by law. To request an accounting, you must submit a written request to Dr. Koff or any staff member of Koff Chiropractic Clinic. The request must state a time period, which may not be longer than six (6) years and may not include dates before April 13, 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 Koff Chiropractic Clinic may charge you for the cost of providing additional lists. Koff Chiropractic Clinic will notify you the costs involved and you can decide to withdraw or modify your request before any costs are incurred.
(G) Receive a paper copy of this privacy notice from Koff Chiropractic Clinic upon request to Dr. Koff or any Koff Chiropractic Clinic staff member.
(H) Complain to Dr. Koff or to the secretary of HHS if you believe your privacy rights have been violated. To file a complaint with Koff Chiropractic Clinic, you must contact Dr. Koff. All complaints must be in writing.
(I) To obtain more information on, or have your questions about your rights answered; you may contact Dr. Koff at (704) 361-0251, or via e-mail at KoffChiro@aol.com..
Koff Chiropractic Clinic’s requirements
Koff Chiropractic Clinic:
(A) Is required by federal law to maintain the privacy of your PHI and to provide you with this privacy notice detailing our legal duties and privacy practices with respect to your PHI.
(B) Is required to maintain a higher level of confidentiality with respect to certain portions of your medical information that is provided for under federal law where state and federal laws conflict, and where state law is more stringent in the area of privacy.
(C) Is required to abide by the terms of this privacy notice.
(D) Reserves to right to change the terms of these privacy notice and to make new privacy notice provisions effective for all of your PHI that it maintains.
(E) Will distribute any revised privacy notice to you prior to implementation.
(F) Will not retaliate against you for filing a complaint.
EFFECTIVE DATE of this latest revision: 01/01/2017