Westchester Family Chiropractic and Wellness Center
550 Mamaroneck Avenue / Suite 103
Harrison, NY 10528
WESTCHESTER FAMILY CHIROPRACTIC
THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
In the course of your care as a patient at Westchester Family Chiropractic we may use or disclose personal and health related information about you in the following ways:
You have the right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the agreement of this office.
If you are not home to receive an appointment reminder or other health related information, a message may be left on your answering machine or with a person in your household. You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.
We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances.
You have a right to receive an accounting of such disclosure made by this office.
Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.
We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information to an address other than your home or, if you would like the information in a specific form, please advise us in writing as to your preferences.
You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information. Requests to inspect, copy, or amend your health related information should be provided to us in writing.
We are required by state and federal law to maintain the privacy of your patient file and the protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are further required by law to abide by the terms of this notice while it is in effect.
We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files.
If you would like further information about our privacy policies and practices, please contact:
550 Mamaroneck Ave. Suite 103
Harrison, NY 10528
You also have a right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and this office and our staff in any manner whatsoever will not disadvantage you.
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Name (Print Please) Signature Date
If you are a minor, or being represented by another party.
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Personal Representative (Print Please) Personal Representative Signature Date