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Notice of Privacy Practices

Chiro One Wellness Centers LLC

2210 Camden Ct. Oakbrook, IL 60523 

Notice of Privacy Practices

This notice describers how medical information about patients may be used and disclosed and how patients can gain access to this information Please review this carefully. The privacy of medical information is important to us. Effective date of this notice: April 14, 2003. This notice will remain in effective until it is revised and/or updated. Questions regarding this notice may be directed to the person listed under “Whom to Contact” at the end of this notice.

Summary

In the course of receiving services from Chiro One Wellness Centers, patients provide us with personal information about their health, with the understanding that this information will be kept confidential. We may obtain health information from examinations, tests, or from others who have provided care to our patients. This notice of our privacy practices is intended to inform patients of the ways we may use information and disclose it to others. We use patient information when providing treatment, and we disclose patient information to other health care providers to assist them in providing treatment. We may disclose information to insurance companies to receive payment. We may use the information within our organization to evaluate quality and improve our processes, and we may disclose patient information as required by law or as permitted by our policies.

Kinds of Information that this Notice Applies To

This notice applies to personal health information, consisting of any information in our possession that would allow someone to identify a
patient and learn something about his or her health.

Who Must Abide By This Notice

All physicians, employees, students, volunteers and other personnel whose work is under the direct control of Chiro One Wellness Centers.

Our Legal Duties

     - We are required by law to maintain the privacy of patient health information.
      - We are required to provide this notice of our privacy practices and legal duties regarding health information to anyone who asks for it.
      - We are required to abide by the terms of this notice until we officially adopt a new notice.

How We May Use or Disclose Your Health Information

We may use patient health information, or disclose it to others, for a number of different reasons. For each reason, we have written a brief explanation. We also provide some examples. These examples do not include all of the specific way we may use or disclose patient information.

  1. Treatment. We will use patient health information to provide medical care and services. This means that our employees, students, volunteers and other’s who work under our direct control, may read patient health information to learn about patients’ medical conditions and use it to make decisions about care. For instance, a chiropractic assistant may read a medical chart in order to provide medical treatment or services. For instances, we may send another doctor the results of laboratory tests we have ordered to be performed.

  2. Payment. We will use patient health information, and disclose it to others, as necessary to obtain payment for the services we provide. For instance, an employee in our central billing office may use a patient’s health information to prepare a bill. We may send that bill, and any health information it contains, to their insurance company. We may also disclose some patient health information to companies who we utilize for payment-related services. For instance, we may give patient information to a collection company that we contract with to collect bills for us. We will not use or disclose more information for payment purposes than is necessary.

  3. Health Care Operations. We may use patient health information for activities that are necessary to operate this organization. This includes reading health information to review the performance of our staff. We may also use patient information to plan services we need to provide, expand, or reduce. We may also provide health information to students who are authorized to receive training here. We may disclose health information as necessary to others who we contract with to provide administrative services. This may include our lawyers, auditors, accreditation services, and consultants.

  4. Legal Requirement to Disclose Information. We will disclose patient information when we are required to do so by law. This includes reporting information to government agencies that have the legal responsibility to monitor the health care system. For instance, we may be required to disclose patient health information if we are audited by Medicare. We will also disclose health information when we are required to do so by a court order or other judicial or administrative process.

  5. Public Health Activities. We will disclose patient health information when required to do so for public health purposes. This includes reporting certain diseases, births, deaths, and reactions to certain treatments.

  6. To Report Abuse. We may disclose patient 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 patient permission.

  7. Law Enforcement. We may disclose patient 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 health information to a federal agency investigating our compliance with federal privacy regulations.

  8. Specialized Purposes. We may disclose patient health information for a number of other specialized purposes. We will only disclose as much information as is necessary for the purpose. For example, we may disclose: -The health information of members of the armed forces as authorized by military command authorities. -Information to coroners, medical examiners, funeral directors and to organ procurement organizations (for organ, eye, or tissue donation) -Information for national security, intelligence, and protection of the President. -Health information about an inmate to a correctional institution or to law enforcement officials to provide the inmate with health care, to protect the health and safety of the inmate and others, and for the safety, administration, and maintenance of the correctional institution. -Health information to an employer for purposes of workers’ compensation and work site safety laws (OSHA, for instance)

  9. To Avert a Serious Threat. We may disclose patient 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.

  10. Family and Friends. We may disclose a patient’ health information to those involved in a patient’s care when the patient approves, or, when the patient is not present or not able to approve, when such disclosure is deemed appropriate in our professional judgment. When the patient is not present, we determine whether the disclosure of the patient’s health information is authorized by law, and if so, disclose the information directly relevant to the person’s involvement with the patient’s health care. We do not disclose health information to a suspected abuser, if, in our professional judgment, we have reason to believe that such a disclosure could cause the patient serious harm. Further, we practice use and disclose information as required by law.

  11. Information to Patients. We may use patient health information to provide patients with additional information. This may include sending appointment reminders to a patient’s address. This may also include sending patient’s information about treatment options or other health-related services that we provide.

  12. Education and Training. To ensure quality control of office procedures and protocols, our offices may be audio and visually recorded to enhance the operations of our employees and administration. These recordings will be of actual patient treatments that occur in our offices that will be used by any and all members of the Chiro One Wellness Centers and any of its affiliates.

Your Rights

  1. Authorization. We will not use or disclose patient health information for any purpose that is not listed in this notice without written authorization. If a patient authorizes us to use or disclose their health information, they have the right to revoke the authorization at any time. For information about how to authorize us to use or disclose patient health information, or about how to revoke an authorization, contact the person listed under “Whom to Contact” at the end of this notice. Patients may revoke an authorization for us to use and disclose their information to the extent that we have taken action in reliance on the authorization. If the authorization is to permit disclosure of information to an insurance company, as a condition of obtaining coverage, other laws may allow the insurer to continue to use patient information to contest claims or coverage, even after revoking the authorization.

  2. Request Restrictions. Patients have the right to ask us to restrict how we use or disclose their health information. We will consider the request. If we do agree, we will comply with the request unless the information is needed to provide the patient with emergency treatment. We cannot agree to restrict disclosures that are required by law.

  3. Confidential Communication. Patients have the right to ask us to communicate with them at a special address or by special means. For example, they may ask us to send mail to a different address rather than to their home. Or they may ask us to speak to them personally on the telephone rather than sending health information by mail. We will not ask them to explain why they are making the request. We will agree to reasonable requests.

  4. Inspect and Receive a Copy of Health Information. Patients have a right to inspect their health information contained in our records, and to receive a copy of it. This right is limited to information about them that is kept in records that are used to make decisions about them. For instance, this includes medical and billing records. If patients want to review or receive a copy of these records, they must make the request in writing. We may charge a fee for the cost of copying and mailing the records. To ask to inspect records, or to receive a copy, contact our Practice Manager at (630)468-1824. We will respond to your request within 14 business days. We may 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.

  5. Amend Health Information. Patients have the right to ask us to amend health information about them which they believe is not correct, or not complete. Patients must make this request in writing, and give us the reason they believe the information is not correct or complete. We will respond to the request in writing within 30 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 the patient, if the information is something patients would not be permitted to inspect or copy, or if it is complete and accurate.

  6. Accounting of Disclosure. Patients have a right to receive an accounting of certain disclosures of their information to others. This accounting will list the times we have given their 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. Patients must tell us the time period they want the list to cover. Patients may not request a time period longer than six years. We cannot include disclosures made before April 14, 2003. 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.

  7. Paper Copy of this Privacy Notice. Patients have a right to receive a paper copy of this notice. If patients receive this notice electronically, they may receive a paper copy by contacting Dr. Sam Wang at (630)468-1824.

  8. Complaints. Patients have a right to complain about our privacy practices, if they think their privacy has been violated. Patients may file a complaint with the person listed under “Whom to Contact” at the end of this notice. A complaint may also be filed directly with the Secretary of the U. S. Department of Health and Human Services, 200 Independence Ave. All complaints 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 health information which we already have, as well as to health information we receive in the future. Before we make any change in the privacy practices described in this notice, we will write a new notice that includes the change. Copies of the new notice will be available in our office. The new notice will include an effective date.

Whom To Contact

Contact the person listed below: Privacy Officer-Dr. Sam Wang (630) 468-1824 -For more information about this privacy notice, or -For more information about our privacy policies, or -To exercise any of the patient rights, as listed on this notice, or -To request a copy of our current notice of privacy practices.