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Notice of Privacy
Practices
Kooistra Chiropractic Clinic
2855 Byron Center Ave. SW
Wyoming, MI. 49519
This
notice describes how medical information about you may be used and
disclosed and how you can get access to this information. Please
review it carefully.
If
you have any questions about this Notice please contact our Privacy
Contact or any staff member in our office.
Our Privacy Contact is Marilyn Bosscher.
This Notice of Privacy Practices describes how we may use and
disclose your protected health information to carry out your
treatment, collect payment for your care and manage the operations
of this clinic. It also describes our policies concerning the use
and disclosure of this information for other purposes that are
permitted or required by law. It also describes your rights to
access and control your protected health information. Protected
health information is information about you, including demographic
information that may identify you, that relates to your past,
present or future physical or mental health condition and other
related health care services.
We are required by federal law to abide by the terms of this Notice
of Privacy Practices. We may change the terms of our notice at any
time. The new notice will be effective for all protected health
information that we maintain at that time. You may obtain revisions
to our Notice of Privacy Practices by accessing our website, calling
our office and requesting that a revised copy be sent to you in the
mail or asking for one the time of your next appointment.
1. Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information Based Upon Your
Implied Consent
By applying to be treated in our office, you are implying consent to
the use and disclosure of your protected health information by your
physician, our staff and others outside of our office that are
involved in your care and treatment for the purpose of providing
health care services to you. Your protected health information may
also be used and disclosed to bill for your health care and to
support the operation of the physicians practice.
Following are examples of the types of uses and disclosures of your
protected health care information we will make, based on this
implied consent . These examples are not meant to be exhaustive, but
to describe the types of uses and disclosures that may be made by
our office.
Treatment: We will use and disclose your protected health
information to provide, coordinate or manage your health care and
any related services. This includes the coordination or management
of your health care with a third party that has already obtained
your permission to have access to your protected health information.
For example, we would disclose your protected health information, as
necessary, to another physician who may be treating you. Your
protected health information may be provided to a physician to whom
you have been referred to ensure that the physician has the
necessary information to diagnose or treat you.
Payment: Your protected health information will be used as needed to
obtain payment for your health care services. This may include
certain activities that your health insurance plan may undertake
before it approves or pays for the health care services we recommend
for you such as; making a determination of eligibility or coverage
for insurance benefits, reviewing services provided to you for
medical necessity, and understanding utilization review activities.
For example, obtaining approval for chiropractic spinal adjustments
may require that your relevant protected health information be
disclosed to the health plan to obtain approval for those services.
Healthcare Operations: We may use or disclose, as needed, your
protected health information in order to support the business
activities of your physicians practice. These activities include,
but are not limited to quality assessment activities, employee
review activities and training of chiropractic students.
For
example, we may disclose your protected health information to
chiropractic interns or precepts that see patients at our office. In
addition, we may use a sign-in sheet at the registration desk where you
will be asked to sign your name and indicate your physician.
Communication between you and your doctor or his assistants may be
recorded to assist us in accurately capturing your responses. We may
also call you by name in the waiting room when your physician is ready
to see you. We may use or disclose your protected health information as
necessary , to contact you to remind you of your appointment.
We will share your protected health information with third party
business associates that perform various activities (e.g., billing,
transcription services ) for the practice. Whenever an arrangement
between our office and a business associate involves the use or
disclosure of your protected health information, we will have a written
contract with that associate that contains terms that will protect the
privacy of your protected health information.
We may use or disclose your protected health information, as
necessary, to provide you with information about treatment alternatives
or other health related benefits and services that may be of interest to
you. We may also use and disclose your protected health information for
other marketing activities. For example, your name and address may be
used to send you a newsletter about our practice and the services we
offer. We may also send you information about products or services that
we believe may be beneficial to you. You may contact our Privacy Contact
to request the materials not be sent to you.
Uses and Disclosures of Protected Health Information That May Be
Made With Your Written Authorization.
Other uses and disclosures of your protected health information will
be made only with your written authorization, unless otherwise permitted
or required by law as described below. You may revoke any of these
authorizations at any time in writing, except to the extent your
physician or physicians practice has taken action in reliance on the use
or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosures That May Be Made
With Your Authorization or Opportunity to Object
In the following instance where we may use and disclose your
protected health information, you have the opportunity to agree or
object to the use or disclosure of all or part of your protected health
information. If you are not present or able to agree or object to the
use or disclosure of the protected health information, then your
physician may, using professional judgment, determine whether disclosure
is in your best interest. In this case, only the protected health
information that is relevant to your health care will be disclosed.
Others Involved in Your Healthcare: Unless you object, we may
disclose to a family member , a relative, a close friend or any other
person you identify, your protected health information that directly
relates to that persons involvement in your health care. If you are
unable to agree or object to such a disclosure, we may disclose such
information as necessary if we determine that it is in your best
interest based on our professional judgment. We may use or disclose
protected health information to notify or assist in notifying a family
member, personal representative or any other person that is responsible
for your care of your location, general condition or death. Finally, we
may use or disclose your protected health information to an authorized
public or private entity to assist in disaster relief efforts and to
coordinate uses and disclosures to family or other individuals involved
in your health care.
Other Permitted and Required Uses and Disclosures That May Be Made
Without Your Consent, Authorization or Opportunity to Object
We may use or disclose your protected health information in the
following situations without your consent or authorization. These
situations include:
Required by Law: We may use or disclose your protected health
information to the extent that the use or disclosure is required by law.
The use or disclosure will be made in compliance with the law and will
be limited to the relevant requirements of the law. You will be
notified, as required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for
public health activities and purposes to a public health authority that
is permitted by law to collect and receive information. The disclosure
will be made for the purpose of controlling disease, injury or
disability. We may also disclose your protected health information, if
directed by the public authority, to a foreign government agency that is
collaborating with the public health authority.
Communicable Diseases: We may disclose protected health information
if authorized by law, to a person who has been exposed to a communicable
disease or may otherwise be at risk of contacting or spreading the
disease or condition.
Health Oversight: We may disclose protected health information to a
health oversight agency for activities authorized by law, such as;
audits, investigations and inspections. Oversight agencies seeking this
information include government agencies that oversee the health care
system, government benefits programs, other government regulatory
programs and civil rights laws.
Abuse or Neglect: We may disclose your protected health information
to a public health authority that is authorized by law to receive
reports of child abuse or neglect. In addition, we may disclose your
protected health information if we believe you have been a victim of
abuse, neglect or domestic violence to the government agency or entity
authorized to receive such information. In this case, the disclosure
will be made consistent with the requirements of applicable federal and
state laws.
Food and Drug Administration: We may disclose your protected health
information to a person or company required by the Food and Drug
Administration to report adverse events, product defects or problems,
biologic product deviations, tract products, to enable product recalls;
to make repairs or replacements or conduct post marketing surveillance,
as required.
Legal Proceedings: We may disclose protected health information in
the course of any judicial or administrative proceedings, in response to
an order of a court or administrative tribunal ( to the extent such
disclosure is expressly authorized), in certain conditions in response
to subpoena, discovery request or other lawful process.
Law Enforcement: We may also disclose protected health information,
so long as applicable legal requirements are met, for law enforcement
purposes. These law enforcement purposes include (1) legal processes and
otherwise required by law, (2) limited information requests for
identification and location purposes, (3) pertaining to victims of
crime, (4) suspicion that death has occurred as a result of criminal
conduct, (5) in the event that a crime occurs on the premises of the
practice, and (6) medical emergency (not on the practices Premises) and
it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose
protected health information to a coroner or medical examiner for
identification purposes, determining cause of death or the coroner or
medical examiner to perform other duties authorized by law. We may also
disclose protected health information to a funeral director, as
authorized by law, in order to permit the funeral director to carry out
his or her duties. We may disclose such information in reasonable
anticipation of death. Protected health information may be used and
disclosed for cadaveric organ, eye and tissue donation.
Research: We may disclose your protected health information to
researchers when an institution review board has approved their research
and that review board has reviewed the research proposal and established
protocols to ensure the privacy of your protected health information.
Criminal Activity: Consistent with applicable federal and state
laws, we may disclose your protected health information, if we believe
that the use or disclosure is necessary to prevent or lessen a serious
and imminent threat to the health or safety of a person or the public.
We may also disclose protected health information if it is necessary for
law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security: When appropriate conditions
apply, we may use or disclose protected health information of
individuals who are Armed Forces personnel (1) for activities deemed
necessary by appropriate military command authorities; (2) for the
purpose of a determination by the Department of Veterans Affairs of your
eligibility for benefits, or (3) to foreign military authorities if you
are a member of that foreign military services. We may disclose your
protected medical information to authorized federal officials for
conducting national security and intelligence activities.
Workers Compensation: We may disclose your health information, as
authorized, to comply with workers compensation laws and other similar
legally established programs.
Inmates: We may use or disclose your protected health information if
you are an inmate of a correctional facility and your physician created
or received your protected health information in the course of providing
care for you.
Required Uses and Disclosures: Under the law, we must make
disclosures to you when required by the Secretary of the Department of
Health and Human Services to investigate or determine our compliance
with the requirements of Section 164.500 et. Seq.
2. Your Rights
Following is a statement of your rights with respect to your
protected health information and a brief description of how you may
exercise these rights.
You have the right to inspect and copy your protected health
information This means you may inspect and obtain a copy of your
protected health information about you that is contained in a designated
record set for as long as we maintain the protected health information.
A designated record set contains medical and billing records and any
other records that your physician and the practice uses for making
decisions about you.
Under federal law, however, you may not inspect or copy the
following records: psychotherapy notes; information compiled in
reasonable anticipation of, or use in, a civil, criminal or
administrative action or proceedings, and the protected health
information that is subject to law that prohibits access to protected
health information. Depending on the circumstances, a decision to deny
access may be reviewable. Please contact our Privacy Contact if you have
questions about your record.
You have a right to request a restriction of your protected health
information This means you may ask us not to use or disclose any part of
your protected health information for the purposes of treatment, payment
or healthcare operations. You may also request that any part of your
protected health information not be disclosed to family members or
friends who may be involved in your care or for notification purposes as
described in this Notice of Privacy Practices. Your request must be in
writing and state the specific restriction requested and to whom you
want the restriction to apply.
Your physician is not required to agree to the restriction that you
may request. If a physician believes it is in your best interest to
permit use and disclosure of your protected health information, your
protected health information will not be restricted. If your physician
does agree to requested restriction, we may not use or disclose your
protected health information in violation of that restriction unless it
is needed to provide emergency treatment. With this in mind, please
discuss any restriction you wish to request with your physician. You may
request a restriction by presenting your request, in writing to the
staff member identified as Privacy Contact at the top of this form. A
simple sentence, Do not send my PHI (Protected Health Information) for
education of Chiropractic Students. Or Do not send any communications to
my home address. Sign and date the request. Ask that the staff provide
you with a photo copy of your request initialed by them. This copy will
serve as a receipt.
You have the right to request to receive confidential communications
from us by alternative means or at an alternative location. We will
accommodate reasonable requests. We may also condition this
accommodation by asking you for information as to how payment will be
handled or specification of an alternative address or other method of
contact. We will not request an explanation from you as to the basis of
the request. Please make your request in writing to our privacy contact.
You may have the right to have your physician amend your protected
health information. This means you may request an amendment of protected
health information about you in a designated record set as long as we
maintain this information. In certain cases, we may deny your request
for an amendment. If we deny your request for amendment, you have the
right to file a statement of disagreement with us and we may prepare a
rebuttal to your statement and will provide you a copy of any such
rebuttal. Please contact our Privacy Contact to determine if you have
any questions about amending your medical record.
You have the right to receive an accounting of certain disclosures
we have made, if any, of your protected health information. This right
applies to disclosures for purposes other than treatment, payment or
health care operations as described in this Notice of Privacy Practices.
It excludes disclosures we may have made to you, for a facility
directory, to family members or friends involved in your care, pursuant
to a duly executed authorization or for notification purposes. You have
a right to receive specific information regarding these disclosures that
occurred after April 14, 2003. The right to receive this information is
subject to certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of this notice from us.
Upon request, even if you have agreed to accept this notice
electronically.
3. Complaints
You may complain to us or the Secretary of Health and Human Services
if you believe your privacy rights have been violated by us. You may
file a complaint with us by notifying our Privacy Contact of your
complaint. We will not retaliate against you for filing a complaint.
Our Privacy Contact is Marilyn Bosscher. You may contact our Privacy
Contact, or any staff member, including your physician at 616-532-2518
or
drkooistra@drkooistra.com
This notice was first published and becomes effective June 20, 2003
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