Phone: Tolleson: (623) 936-5678 | Phoenix: (602) 353-1234
Privacy Statement
The Accident Doctor Chiropractic Clinic, PLLC
Notice of Privacy Practices
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.
The Accident Doctor Chiropractic Clinic, PLLC, is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.
Disclosure of Your Health Care Information
Treatment
We may disclose your healthcare information to other healthcare professionals within our practice for the purpose of treatment, payment, or healthcare operations.
“On occasion, it may be necessary to seek consultation regarding your condition from other healthcare providers associated with The Accident Doctor Chiropractic Clinic, PLLC.”
“It is our policy to provide a substitute healthcare provider, authorized by The Accident Doctor Chiropractic Clinic, PLLC, to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary healthcare provider’s absence due to vacation, sickness, or other emergency situation.”
Payment
We may disclose your health information to your insurance provider for the purpose of payment or health care operations.
“As a courtesy to our patients, we will submit an itemized billing statement to your insurance carrier for the purpose of payment to The Accident Doctor Chiropractic Clinic, PLLC, for health care services rendered. If you pay for your health care services personally, we will, as a courtesy, provide an itemized billing to your insurance carrier for the purpose of reimbursement to you. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the health care services received.”
Workers’ Compensation
We may disclose your health information as necessary to comply with State Workers’ Compensation Laws.
Emergencies
We may disclose your health information to notify or assist in notifying a family member or another person responsible for your care about your medical condition or in the event of an emergency or of your death.
Public Health
As required by law, we may disclose your health information to public health authorities for purposes related to preventing or controlling disease; injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.
Judicial and Administrative Proceedings
We may disclose your health information in the course of any administrative or judicial proceeding.
Law Enforcement
We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness, or missing person, complying with a court order or subpoena, and other law enforcement purposes.
Deceased Persons
We may disclose your health information to coroners or medical examiners.
Organ Donation
We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.
Public Safety
It may be necessary to disclose your health information to appropriate persons to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
Specialized Government Agencies
We may disclose your health information for military, national security, prisoner, and government benefits purposes.
Marketing
We may contact you for marketing purposes or fundraising purposes, as described below: (example)
“As a courtesy to our patients, it is our policy to call your home on the evening prior to your scheduled appointment to remind you of your appointment time. If you are not at home, we leave a reminder message on your answering machine or with the person answering the phone. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment, along with a request to call our office if you need to cancel or reschedule your appointment.”
“It is our practice to participate in charitable events to raise awareness, food donations, gifts money, etc. During these times, we may send you a letter, postcard, or invitation or call your home to invite you to participate in the charitable activity. We will provide you with information about the type of activity, the dates and times, and request your participation in such an event. It is not our policy to disclose any personal health information about your condition for the purpose of The Accident Doctor Chiropractic Clinic, PLLC-sponsored fundraising events.”
Change of Ownership
In the event that The Accident Doctor Chiropractic Clinic, PLLC, is sold or merged with another organization, your health information/record will become the property of the new owner.
Treatment
We may disclose your healthcare information to other healthcare professionals within our practice for the purpose of treatment, payment, or healthcare operations.
“On occasion, it may be necessary to seek consultation regarding your condition from other healthcare providers associated with The Accident Doctor Chiropractic Clinic, PLLC.”
“It is our policy to provide a substitute healthcare provider, authorized by The Accident Doctor Chiropractic Clinic, PLLC, to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary healthcare provider’s absence due to vacation, sickness, or other emergency situation.”
Payment
We may disclose your health information to your insurance provider for the purpose of payment or health care operations.
“As a courtesy to our patients, we will submit an itemized billing statement to your insurance carrier for the purpose of payment to The Accident Doctor Chiropractic Clinic, PLLC, for health care services rendered. If you pay for your health care services personally, we will, as a courtesy, provide an itemized billing to your insurance carrier for the purpose of reimbursement to you. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the health care services received.”
Workers’ Compensation
We may disclose your health information as necessary to comply with State Workers’ Compensation Laws.
Emergencies
We may disclose your health information to notify or assist in notifying a family member or another person responsible for your care about your medical condition or in the event of an emergency or of your death.
Public Health
As required by law, we may disclose your health information to public health authorities for purposes related to preventing or controlling disease; injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.
Judicial and Administrative Proceedings
We may disclose your health information in the course of any administrative or judicial proceeding.
Law Enforcement
We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness, or missing person, complying with a court order or subpoena, and other law enforcement purposes.
Deceased Persons
We may disclose your health information to coroners or medical examiners.
Organ Donation
We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.
Public Safety
It may be necessary to disclose your health information to appropriate persons to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
Specialized Government Agencies
We may disclose your health information for military, national security, prisoner, and government benefits purposes.
Marketing
We may contact you for marketing purposes or fundraising purposes, as described below: (example)
“As a courtesy to our patients, it is our policy to call your home on the evening prior to your scheduled appointment to remind you of your appointment time. If you are not at home, we leave a reminder message on your answering machine or with the person answering the phone. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment, along with a request to call our office if you need to cancel or reschedule your appointment.”
“It is our practice to participate in charitable events to raise awareness, food donations, gifts money, etc. During these times, we may send you a letter, postcard, or invitation or call your home to invite you to participate in the charitable activity. We will provide you with information about the type of activity, the dates and times, and request your participation in such an event. It is not our policy to disclose any personal health information about your condition for the purpose of The Accident Doctor Chiropractic Clinic, PLLC-sponsored fundraising events.”
Change of Ownership
In the event that The Accident Doctor Chiropractic Clinic, PLLC, is sold or merged with another organization, your health information/record will become the property of the new owner.
Your Health Information Rights
Changes to this Notice of Privacy Practices
The Accident Doctor Chiropractic Clinic, PLLC, reserves the right to amend this Notice of Privacy Practices at any time in the future and will make the new provisions effective for all information that it maintains. Until such amendment is made, The Accident Doctor Chiropractic Clinic, PLLC, is required by law to comply with this Notice.
The Accident Doctor Chiropractic Clinic, PLLC, is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your Privacy Rights, please contact Lawrence Paule by calling this office at (623) 936-5678 or (602) 353-1234. If Lawrence Paule is not available, you may make an appointment for a personal conference in person or by telephone within two working days.
Complaints
Complaints about your Privacy Rights or the way The Accident Doctor Chiropractic Clinic, PLLC, has handled your health information should be directed to Lawrence Paule by calling this office at (623) 936-5678 or (602) 353-1234. If Lawrence Paule is not available, you may make an appointment for a personal conference in person or by telephone within two working days.
If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:
DHHS, Office of Civil Rights
200 Independence Ave SW #509F
Hubert H. Humphrey Building
Washington, DC 20201
This notice is effective as of _____/______/______
I have read the Privacy Notice and understand my rights contained in the notice.
By way of my signature, I provide The Accident Doctor Chiropractic Clinic, PLLC, with my authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.
________________________________
Patient Name (Print)
_________________________________
Patient’s Signature
_________________________________
Authorized Facility Signature
PRIVACY PRACTICES ACKNOWLEDGEMENT
The Accident Doctor Chiropractic Clinic, PLLC Acknowledgment Form
I have received the Notice of Privacy Practices, and I have been provided an opportunity to review it.
Name____________________________
Birth Date_________________________
Signature_________________________
Date_____________________________