May 5, 2020
By Chiro One Wellness Centers
Chiro One Wellness Centers LLC
2625 Butterfield Rd #301N Oak Brook, IL 60523
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS CAREFULLY.
In the course of receiving care from an affiliate of Chiro One Wellness Centers, LLC (“Chiro One,” “we,” or “us”), you provide us with “protected health information,” which is individually identifiable health information deserving special treatment under the Health Insurance Portability and Accountability Act (“HIPAA”), as amended. We may obtain your protected health information from conversations with you, questionnaires, examinations, tests, and from others who have provided or will provide care to you. This Notice of Privacy Practices informs you how we may use and disclose your protected health information, as well as your legal rights with respect to such information.
Our Legal Duties
We are required by law to:
- maintain the privacy of protected health information, as provided by HIPAA;
- provide this Notice to you of our privacy practices and legal duties regarding your protected health information;
- notify you following any breach of unsecured protected health information which affects you; and
- abide by the terms of this Notice until we adopt any new Notice.
How We May Use or Disclose Your Protected Health Information
We may use your protected health information, or disclose it to others, for the following purposes allowed by HIPAA; all other uses or disclosures require your written authorization (the examples do not include every possible use or disclosure and are representative only):
- Treatment. We will use your protected health information to provide medical care and services. Our doctors, employees, and others who work under our direct control, may read protected health information to learn about your medical history and, in turn, use it to make decisions about your care. We may also disclose protected health information to another doctor who is providing care to you.
- Payment. We will use your protected health information, and disclose it to others, as necessary to obtain payment for the services we provide. Our Billing Department employees may use protected health information to prepare a bill. We may send that bill, and any protected health information it contains, to your insurance company. We may also disclose protected health information to companies who we utilize for payment-related services. We will not use or disclose more information for payment purposes than is necessary.
- Health Care Operations. We may use protected health information for activities that are necessary to operate our organization. This includes reading protected health information to review the performance of our staff or to plan services we need to provide, expand, or reduce. We may disclose protected health information to others with whom we contract to provide administrative services, including our attorneys, auditors, accreditation services, and consultants. We may use protected health information to ensure quality control of office procedures and protocols, including audio and visual recording our offices to enhance our operations.
- Legal Requirement. We will disclose protected health information when required to do so by law. This includes reporting information to government agencies which have the legal responsibility to monitor the healthcare system, such as Medicare. We will also disclose protected health information when we are required to do so by a court order or other judicial or administrative process.
- Public Health Activities. We will disclose protected health information when required to do so for public health purposes. This includes reporting certain diseases, births, deaths, and reactions to certain treatments.
- Reporting of Abuse. We may disclose protected health information when the information relates to a victim of abuse, neglect, or domestic violence. We will make this report only in accordance with laws that require or allow such reporting, or with your permission.
- Law Enforcement. We may disclose protected health information for law enforcement purposes. This includes providing information to help locate a suspect, fugitive, material witness, or missing person, or in connection with suspected criminal activity. We must also disclose protected health information to a federal agency investigating our compliance with federal privacy regulations.
- Specialized Purposes. We may disclose protected health information for a number of other specialized purposes, but we will only disclose as much information as is necessary for the purpose. For example, we may disclose your protected health information:
- to the armed forces as authorized by military command authorities;
- to coroners, medical examiners, funeral directors, and organ procurement organizations (for organ, eye, or tissue donation);
- for national security, intelligence, and protection of the President;
- to a correctional institution or to law enforcement officials to provide an inmate with health care, to protect the health and safety of the inmate and others, or for the safety, administration, and maintenance of the correctional institution; or
- to an employer for purposes of workers’ compensation and work site safety laws
- Averting a Serious Threat. We may disclose protected health information if we decide that the disclosure is necessary to prevent serious harm to the public or to an individual. The disclosure will only be made to someone who is able to prevent or reduce the threat.
- Family and Friends. We may disclose protected health information to those involved in your care when you approve, or, when you are not present or not able to approve, when such disclosure is deemed appropriate in our professional judgment.
When you are not present, we determine whether the disclosure of your protected health information is authorized by law, and, if so, disclose the information directly relevant to the person’s involvement with your healthcare. We do not disclose protected health information to a suspected abuser, if, in our professional judgment, we have reason to believe that such a disclosure could cause serious harm.
- Information to Patients. We may use protected health information to provide you with additional information. This may include sending you appointment reminders or information regarding treatment options or other health-related services that we provide.
Your Legal Rights
- Authorization. We will not use or disclose protected health information for any purpose that is not listed in this Notice without your written authorization. If, at our request, you authorize us in writing to use or disclose protected health information for purposes not listed above, such as for our marketing purposes, you have the right to revoke the authorization at any time in writing (but not to the extent we have already relied upon your original authorization). If the authorization is to permit disclosure of protected health information to an insurance company as a condition of obtaining coverage, other laws may allow the insurer to continue to use such information to contest claims or coverage, even after you revoke the authorization.
- Restrictions. You have the right to request us to restrict certain uses or disclosures of your protected health information. After consideration, we may comply with your request, but we may always use or disclose your health information to provide emergency treatment to you. Pursuant to 45 CFR 164.522(a), we have the right not to honor your request, except if you request us to not provide protected health information to your health insurer when you have paid for our services in full.
- Confidential Communication. You have the right to request us to restrict certain uses or disclosures of your protected health information. After consideration, we may comply with your request, but we may always use or disclose your health information to provide emergency treatment to you. Pursuant to 45 CFR 164.522(a), we have the right not to honor your request, except if you request us to not provide protected health information to your health insurer when you have paid for our services in full.
- Copy of Health Information. You have the right to inspect your protected health information and to receive a copy of it. This right is limited to certain information, as provided in 45 CFR 164.524. If you want to review or receive a copy of your records, you must make a written request to our Clinical Operations Manager identified below. We may charge a fee for the cost of copying and mailing the records. We will respond to your request within 15 business days. We may, however, deny access to certain information. If we do, we will give the reason in writing. We will also explain how patients may appeal the decision.
- Amendment of Health Information. You have the right to request us to amend protected health information if you believe it is not correct or not complete. This right is limited to certain information, as provided in 45 CFR 164.526. Any such request must be in writing and specify the reason the information is not correct or complete. We will respond to the request in writing within 60 days. We may deny the request if we did not create the information, if it is not part of the records we use to make decisions about you, if the information would not be permitted for you to inspect or copy, or if it is complete and accurate.
- Accounting of Disclosure. You have the right to receive an accounting of certain disclosures of your protected health information to others. The list will include dates of the disclosures, the names of the people or organizations to whom the information was disclosed, a description of the information, and the reason. Any such request must be in writing and must specify the time period the list will cover, but such time period may not be more than six (6) years prior to your request. Disclosures for the following reasons will not be included on the list: disclosures for treatment, payment, or health care operations; disclosures for national security purposes; disclosures to correctional or law enforcement personnel; disclosures that patients have authorized; and disclosures made directly to the patient.
- Paper Copy of this Privacy Notice. You have a right to receive a paper copy of this Notice. This Notice is also available on our website at www.chiroone.net/privacynotice. If you receive this Notice electronically, you may receive a paper copy by contacting our Privacy Officer identified below.
- Complaints. You have the right to complain about our privacy practices if you believe your privacy has been violated. You may file a complaint with our Privacy Officer identified below or with the Secretary of the U. S. Department of Health and Human Services. Any such complaint must be in writing. We will not retaliate against anyone filing a complaint.
Our Right to Change This Notice
We reserve the right to change our privacy practices, as described in this Notice, at any time. We reserve the right to apply these changes to any protected health information which we already have, as well as to protected health information we receive in the future. Before we make any change in the privacy practices described in this Notice, we will adopt a new Notice that includes the change and its effective date. The new Notice will be available in our office and on our website at www.chiroone.com/privacynotice.
Whom To Contact
To assert your legal rights as provided above, contact Chiro One’s Privacy Officer, Dr. Sam Wang, at (630) 468-1824 or email@example.com.
- For more information about this Notice;
- For more information about our privacy policies;
- To exercise any of the patient rights, as listed on this Notice; or
- To request a copy of our current Notice of Privacy Practices.
Contact Chiro One’s Medical Records Department at (630) 320-6422 or firstname.lastname@example.org:
To request a copy of your protected health information.