CHIROPRACTIC CARE CENTER
MIDDLE CREEK RD SUITE #103
SEVIERVILLE, TN 37862
NOTICE OF PRIVACY PRACTICES
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.
Chiropractic Practice (the "Practice"), 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
THE PRACTICE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
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:
(a.) 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 staffer not, so that it may
provide, coordinate, plan and manage your health care. For example, a
chiropractor treating you for low back pain may need to know and obtain the
results of your latest physician examination or last treatment plan.
(b.) 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.
(c.) 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.
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
(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
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
(ii) 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.
USE & DISCLOSURES WHICH MAY BE PERMITTED OR REQUIRED BY LAW
Practice may also use and disclose your PHI, without your consent or
authorization in the following instances:
(a) 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.
(b) Business Associate - The Practice may use and disclose
PHI to one or more of its business associates if the Practice obtains
satisfactory written assurance, hi
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
(c) Personal Representative - The Practice may use and
disclose PHI: a person who, under applicable law, has the authority to
represent you hi making decisions related to your health care.
(d) 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.
(e) 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.
(f) 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.
(g) 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.
(h) Judicial and Administrative Proceeding - The Practice
may use and disclose PHI hi response to a court order or a lawfully issued
(i) 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.
(j) 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.
(k) 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.
(1) Research - The Practice may vise and disclose PHI
subject to applicable legal requirements if the Practice is involved in
(m)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.
(n) Specialized Government Functions -The Practice may use
and disclose PHI when authorized by law with regard to certain military and
(o) 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.
(p) National Security and Intelligence Activities - The
Practice may use and disclose PHI to authorized governmental officials with
necessary intelligence information for national security activities.
(q) 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.
and/or disclosures, other than those described above, will be made only with
your written Authorization.
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.
(b) 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.
(c) 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
(d) 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.
(e) 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
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
(f) 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 hi 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.
(g) Receive a paper copy of this Privacy Notice from the Practice (as
provided by Privacy Rule Section 164.520(b)(l)(iv)(F)) upon request to the
Practice's Privacy Officer.
(h) Complain to the Practice or to the Secretary of HHS (as provided by
Privacy Rule Section 164.520(b)(l)(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:
Name: Jennifer Reeping
Address: 1011 Middle Creek Rd Suite #103
Telephone No.: (865) 908-2699
1011 MIDDLE CREEK RD SUITE #103
SEVIERVILLE, TN 37862
Is required by federal law to maintain the privacy of your PHI and to
provide you with this Privacy Notice detailing the Practice's legal duties
and privacy practices with respect to your PHI.
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
Will distribute any revised Privacy Notice to you prior to implementation,
(d.) Will not retaliate against you for filing a complaint.
is in effect as of 04/15/03.
subscribing my name below, I acknowledge receipt of a copy of this Notice, and
my understanding and my agreement to its terms.