New Patient Forms
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.
If you have any questions about this Notice, please contact 734-237-8916.
Triumph Chiropractic PLLC provides chiropractic services to you as a patient. Triumph Chiropractic PLLC receives and maintains your medical information in the course of providing these services to you. When doing so, Triumph Chiropractic PLLC is required by law to maintain the privacy of your health information and to provide you with this notice of our legal duties and privacy practices with respect to your health information. Triumph Chiropractic PLLC will follow the terms of this notice.
The effective date of this Notice is September 23, 2013. We must follow the terms of this Notice until it is replaced. We reserve the right to change the terms of this Notice at any time. If we make substantive changes to this Notice, we will revise it and send a new Notice to all subscribers covered by us at that time. We reserve the right to make the new changes apply to all your medical information maintained by us before and after the effective date of the new Notice.
You have the right to get a paper copy of this Notice from us, even if you have agreed to accept this Notice electronically. Please contact 734-237-8916.
Generally, federal privacy laws regulate how we may use and disclose your health information. In some circumstances, however, we may be required to follow Michigan state law. In either event, we will comply with the appropriate law to protect your health information.
WAYS WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION
WITHOUT YOUR PERMISSION
We must have your written authorization to use and disclose your health information, except for the following uses and disclosures.
To You or Your Personal Representative: We may release your health information to you or to your personal representative (someone who has the legal right to act for you).
For Treatment: We may use or disclose health information about you for the purpose of helping you get services you need. For example, we may disclose your health information to health care providers in connection with disease management programs.
For Payment: We may use or disclose your health information for our payment-related activities and those of health care providers and other health plans, including, for example: submitting claims to a health insurance company; determining your eligibility for benefits.
For Health Care Operations: We may use and disclose your health information in order to support our business activities, including, for example: to conduct quality assessment and improvement activities; to prevent, detect and investigate fraud and abuse; to communicate with you about treatment alternatives or other health-related benefits and services.
We may use or disclose parts of your health information to offer you information that may be of interest to you. For example, we may use your name and address to send you newsletters or other information about our activities.
We may also disclose your health information to other providers and health plans that have a relationship with you for certain of their health care operations. For example, we may disclose your health information for their quality assessment and improvement activities or for health care fraud and abuse detection.
To Others Involved in Your Care. We may under certain circumstances disclose to a member of your family, a relative, a close friend or any other person you identify, the health information directly relevant to that person’s involvement in your health care or payment for health care. For example, we may discuss a your treatments with you in the presence of a friend or relative, unless you object.
As required by law. We will use and disclose your health information if we are required to do so by law. For example, we will use and disclose your health information in responding to court and administrative orders and subpoenas, and to comply with workers’ compensation or other similar laws. We will disclose your health information when required by the Secretary of the U.S. Department of Health and Human Services.
For Health Oversight Activities. We may use and disclose your health information for health oversight activities such as governmental audits and fraud and abuse investigations.
For Matters in the Public Interest. We may use and disclose your health information without your written permission for matters in the public interest, including, for example: public health and safety activities, including disease and vital statistic reporting and Food and Drug Administration oversight, to report victims of abuse, neglect, or domestic violence to government authorities, including a social service or protective service agency.
For Research. We may use your health information to perform select research activities (such as research related to the prevention of disease or disability), provided that certain established measures to protect the privacy of your health information are in place.
To Business Associates. We may release your health information to business associates we hire to assist us. Each business associate must agree in writing to ensure the continuing confidentiality and security of your medical information.
USES AND DISCLOSURES OF HEALTH INFORMATION
BASED UPON YOUR WRITTEN AUTHORIZATION
If none of the above reason applies, then we must get your written authorization to use or disclose your health information. Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not disclose the information. You may take back or “revoke” your written authorization, except if we have already acted based on your authorization. Also, you may not revoke your authorization if it was obtained as a condition for obtaining insurance coverage and other law provides an insurer with the right to contest a claim under the insurance policy. To revoke an authorization, or to obtain an authorization form, call 734-237-8916
YOUR RIGHTS
You have the right to inspect and copy your Health Information. This means you may inspect and obtain a paper or electronic copy of the health information that we keep in our records for as long as we maintain those records. You must make this request in writing. Under certain circumstances, we may deny you access to your health information, for instance, if part of certain psychotherapy notes, or if collected for use in court or at hearings. In such cases, you may have the right to have our decision reviewed. Please contact our Customer Service Department if you have questions about seeing or copying your health information.
You have the right to amend your Health Information. If you feel that the health information we have about you is incorrect or incomplete, you can make a written request to us to amend that information. We can deny your request for certain limited reasons, but we must give you a written reason for our denial.
You have the right to an accounting of disclosures we have made of your Health Information. Upon written request to us, you have the right to receive a list of our disclosures of your health information, except when you have authorized those disclosures or if the releases are made for treatment, payment or health care operations. This right is limited to six years of information, starting from the date you make the request.
You have the right to request confidential communications of your Heath Information.
You have the right to request that we communicate with you about health information in a certain way or at a certain location. Your request must be in writing. For example, you can ask that we only contact you at home or only at a certain address or only by mail.
You have the right to request restrictions on how we use or disclose your Health Information. You may request that we restrict how we use or disclose your health information. We do not have to agree to your request except for requests for a restriction on disclosure to another health plan if the disclosure is for payment or health care operation, is not required by law and pertains only to a health care item or service which has been paid for in full. You may also opt out of communications relating to fundraising (information on how to opt out should be included on each fundraising communication).
You have the right to restrict certain disclosures of your Health Information. Under circumstances where you or someone you your behalf pays in cash or cash equivalents (out of pocket) for the entire services you received, you may restrict disclosures of your Health Information to health plans.
Right to receive notice of a breach. If your unencrypted information is impermissibly disclosed, you have a right to receive notice of that breach unless, based on an adequate risk assessment, it is determined that the probability is low that your health information has been compromised.
How to Use Your Rights under this Notice. If you want to use your rights under this Notice, you may call us or write to us. In some cases, we may charge you a nominal, cost-based fee to carry out your request.
COMPLAINTS
You may complain to Triumph Chiropractic PLLC or to 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 calling 734-237-8916. We will not retaliate against you for filing a complaint.
To complain to the federal government, you may write to: Region V, Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave. Ste. 240, Chicago, Illinois 60601. Voicemail: 312-866-2359, Fax, 312-866-1807, TDD: 312-353-1807. There will be no negative consequences to you for filing a complaint to the federal government.
