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:

 

  • Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
  • Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are or may be responsible for the payment of services provided to you.
  • Your name, address, phone number, and your health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you.

 

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.

 

  • If we provide health care services to you in an emergency.
  • If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so.
  • If there are substantial barriers to communicating with you, but in our professional judgement we believe that you intend for us to provide care.
  • If we are ordered by the courts or another appropriate agency.

 

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:

 

WestchesterFamily Chiropractic

550 Mamaroneck Ave. Suite 103

Harrison, NY 10528

(914) 346-5200

 

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.

 

 

 

_______________________   ____________________________          _______________

Name (Print Please)                Signature                                                   Date

 

 

 

 

If you are a minor, or being represented by another party.

 

________________________________  __________________________       _____________

Personal Representative (Print Please)     Personal Representative Signature   Date