AMIS CHIROPRACTIC PRIVACY NOTICE TO PATIENTS

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION.

 PLEASE REVIEW THIS NOTICE CAREFULLY.

 POLICY STATEMENT

Amis Chiropractic is committed to maintaining the privacy of your protected health information ("PHI"), which includes information about your medical condition and the care and treatment you receive from Amis Chiropractic and other health care providers.  This Notice details how your PHI may be used and disclosed to third parties for purposes of your care, payment for your care, health care operations of Amis Chiropractic, and for other purposes permitted or required by law.  This Notice also details your rights regarding your PHI.

USE OR DISCLOSURE OF PHI

Amis Chiropractic may use and/or disclose your PHI for purposes related to your care, payment for your care, and health care operations of Amis Chiropractic.  The following are examples of the types of uses and/or disclosures of your PHI that may occur.  These examples are not meant to include all possible types of use and/or disclosure.

1.       Care - In order to provide care to you, Amis Chiropractic will provide your PHI to those health care professionals, whether on Amis Chiropractic's staff or not, directly involved in your care so that they may understand your medical condition and needs and provide advice or treatment (e.g., your physician).  For example, your physician may need to know how your condition is responding to the treatment provided by Amis Chiropractic.

2.       Payment – In order to get paid for some or all of the health care provided by Amis Chiropractic, Amis Chiropractic may provide your PHI, directly or through a billing service, to appropriate third party payers, pursuant to their billing and payment requirements.  For example, Amis Chiropractic may need to provide your health insurance carrier with information about health care services that you received from Amis Chiropractic so that Amis Chiropractic can be properly reimbursed.

3.       Health Care Operations – In order for Amis Chiropractic to operate in accordance with applicable law and insurance requirements and in order for Amis Chiropractic to provide quality and efficient care, it may be necessary for Amis Chiropractic to compile, use and/or disclose your PHI.  For example, Amis Chiropractic may use your PHI in order to evaluate the performance of Amis Chiropractic's personnel in providing care to you.

AUTHORIZATION NOT REQUIRED

Amis Chiropractic may use and/or disclose your PHI, without a written Authorization from you, in the following instances:

1.       De-identified Information – Your PHI is altered so that it does not identify you and, even without your name, cannot be used to identify you.

2.       Business Associate – To a business associate, which is someone who Amis Chiropractic contracts with to provide a service necessary for your treatment, payment for your treatment and health care operations (e.g., billing service or transcription service).  Amis Chiropractic will obtain satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI.

3.       Personal Representative – To a person who, under applicable law, has the authority to represent you in making decisions related to your health care.

4.       Public Health Activities – Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent or control disease, injury or disability.  This includes reports of child abuse or neglect.

5.       Federal Drug Administration – If required by the Food and Drug Administration to report adverse events, product defects or problems or biological product deviations, or to track products, or to enable product recalls, repairs or replacements, or to conduct post marketing surveillance.

6.       Abuse, Neglect or Domestic Violence – To a government authority if Amis Chiropractic is required by law to make such disclosure.  If Amis Chiropractic is authorized by law to make such a disclosure, it will do so if it believes that the disclosure is necessary to prevent serious harm or if Amis Chiropractic believes that you have been the victim of abuse, neglect or domestic violence.  Any such disclosure will be made in accordance with the requirements of law, which may also involve notice to you of the disclosure.

7.       Health Oversight Activities – Such activities, which must be required by law, involve government agencies involved in oversight activities that relate to the health care system, government benefit programs, government regulatory programs and civil rights law.  Those activities include, for example, criminal investigations, audits, disciplinary actions, or general oversight activities relating to the community's health care system.

8.      Judicial and Administrative Proceeding – For example, Amis Chiropractic may be required to disclose your PHI in response to a court order or a lawfully issued subpoena. 

9.       Law Enforcement Purposes – In certain instances, your PHI may have to be disclosed to a law enforcement official for law enforcement purposes.   Law enforcement purposes include: (1) complying with a legal process (i.e., subpoena) or as required by law; (2) information for identification and location purposes (e.g., suspect or missing person); (3) information regarding a person who is or is suspected to be a crime victim; (4) in situations where the death of an individual may have resulted from criminal conduct; (5) in the event of a crime occurring on the premises of Amis Chiropractic; and (6) a medical emergency (not on Amis Chiropractic's premises) has occurred, and it appears that a crime has occurred.

10.    Coroner or Medical Examiner – Amis Chiropractic may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death, or to a funeral director as permitted by law and as necessary to carry out its duties. 

11.    Organ, Eye or Tissue Donation – If you are an organ donor, Amis Chiropractic may disclose your PHI to the entity to whom you have agreed to donate your organs.

12.    Research – If Amis Chiropractic is involved in research activities, your PHI may be used, but such use is subject to numerous governmental requirements intended to protect the privacy of your PHI such as approval of the research by an institutional review board and the requirement that protocols must be followed. 

13.    Avert a Threat to Health or Safety – Amis Chiropractic may disclose your PHI if it believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to an individual who is reasonably able to prevent or lessen the threat.

14.    Specialized Government Functions – When the appropriate conditions apply, Amis Chiropractic may use PHI 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 Veteran Affairs of eligibility for benefits; or  (3) to a foreign military authority if you are a member of that foreign military service.  Amis Chiropractic may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities including the provision of protective services to the President or others legally authorized.

15.    Inmates – Amis Chiropractic may disclose your PHI to a correctional institution or a law enforcement official if you are an inmate of that correctional facility and your PHI is necessary to provide care and treatment to you or is necessary for the health and safety of other individuals or inmates. 

16.   Workers' Compensation – If you are involved in a Workers' Compensation claim, Amis Chiropractic may be required to disclose your PHI to an individual or entity that is part of the Workers' Compensation system.

17.    Disaster Relief Efforts – Amis Chiropractic may use or disclose your PHI to a public or private entity authorized to assist in disaster relief efforts.

18.    Required by Law – If otherwise required by law, but such use or disclosure will be made in compliance with the law and limited to the requirements of the law.

AUTHORIZATION

Uses and/or disclosures, other than those described above, will be made only with your written Authorization, which you may revoke at any time.

PRIVATE CONSULTATIONS

Amis Chiropractic is set up in such a way that your discussions with the doctor may be overheard in the waiting area.  If you ever have a question or concern that you would prefer be private, simply request a private consultation and one will be provided for you.

TESTIMONIALS

Amis Chiropractic may, at some time in the future, ask you for a testimonial and / or photograph with your doctor.  This information may be used on the "Testimonial Board” or in one of our printed advertisements.  If you would prefer not to give a testimonial or you would prefer not to have your testimonial used in the printed advertisements please let us know.

APPOINTMENT REMINDER

Amis Chiropractic may, from time to time, contact you to provide appointment reminders.  The reminder may be in the form of a letter or postcard.  Amis Chiropractic will try to minimize the amount of information contained in the reminder.  Amis Chiropractic may also contact you by phone and, if you are not available, Amis Chiropractic will leave a message for you.

TREATMENT ALTERNATIVES/BENEFITS

Amis Chiropractic may, from time to time, contact you about treatment alternatives, or other health benefits or services that may be of interest to you.

YOUR RIGHTS

You have the right to:

1.       Revoke any Authorization, in writing, at any time.  To request a revocation, you must submit a written request to Amis Chiropractic's Privacy Officer (Dr. Amis).

2.       Request restrictions on certain use and/or disclosure of your PHI as provided by law.  However, Amis Chiropractic is not obligated to agree to any requested restrictions.  To request restrictions, you must submit a written request to Amis Chiropractic's Privacy Officer.  In your written request, you must inform Amis Chiropractic of what information you want to limit, whether you want to limit Amis Chiropractic"s use or disclosure, or both, and to whom you want the limits to apply.  If Amis Chiropractic agrees to your request, Amis Chiropractic will comply with your request unless the information is needed in order to provide you with emergency treatment.

3.       Receive confidential communications of PHI by alternative means or at alternative locations.  You must make your request in writing to Amis Chiropractic's Privacy Officer.  Amis Chiropractic will accommodate all reasonable requests.

4.       Inspect and copy your PHI as provided by law.  To inspect and copy your PHI, you must submit a written request to Amis Chiropractic's Privacy Officer.  In certain situations that are defined by law, Amis Chiropractic may deny your request, but you will have the right to have the denial reviewed.  Amis Chiropractic can charge you a fee for the cost of copying, mailing or other supplies associated with your request.

5.       Amend your PHI as provided by law.  To request an amendment, you must submit a written request to Amis Chiropractic's Privacy Officer.  You must provide a reason that supports your request.  Amis Chiropractic may deny your request if it is not in writing, if you do not provide a reason and support of your request, if the information to be amended was not created by Amis Chiropractic (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by Amis Chiropractic, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete.  If you disagree with Amis Chiropractic’s denial, you have the right to submit a written statement of disagreement.

6.       Receive an accounting of disclosures of your PHI as provided by law.  To request an accounting, you must submit a written request to Amis Chiropractic's Privacy Officer.  The request must state a time period which may not be longer than six years and may not include the dates before April 14, 2003.  The request should indicate in what form you want the list (such as a paper or electronic copy).  The first list you request within a 12-month period will be free, but Amis Chiropractic may charge you for the cost of providing additional lists in that same 12-month period.  Amis Chiropractic will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred.

7.       Receive a paper copy of this Privacy Notice from Amis Chiropractic upon request to Amis Chiropractic's Privacy Officer.

8.       Complain to Amis Chiropractic’s Privacy Officer, or to the Secretary of Health and Human Services, Office of Civil Rights, Hubert H. Humphrey Building, 200 Independence Avenue, S. W., Room 509F HHH Building, Washington, D.C. 20201.  Or you may contact a regional office of the Office of Civil Rights, which can be found at www.hhs.gov/ocr/regmail.html.  To file a complaint with Amis Chiropractic, you must contact Amis Chiropractic's Privacy Officer.  All complaints must be in writing.

9.       To obtain more information on, or have your questions about your rights answered; you may contact Amis Chiropractic's Privacy Officer, Dr. Robert Amis Jr. at (574) 825-8118.

PRACTICE'S REQUIREMENTS

Amis Chiropractic:

1.       Is required by law to maintain the privacy of your PHI and to provide you with this Privacy Notice of Amis Chiropractic's legal duties and privacy practices with respect to your PHI.

2.       Is required to abide by the terms of this Privacy Notice.

3.       Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.

4.       Will not retaliate against you for making a complaint.

5.       Must make a good faith effort to obtain from you an acknowledgement of receipt of this Notice.

6.       Will post this Privacy Notice on Amis Chiropractic's web site, if Amis Chiropractic maintains a web site.

7.       Will provide this Privacy Notice to you by e-mail if you so request.  However, you also have the right to obtain a paper copy of this Privacy Notice.

EFFECTIVE DATE

This Notice is effective as of April 14^th, 2003.

ACKNOWLEDGEMENT

I acknowledge that I have received a copy of Amis Chiropractic’s Privacy Notice that has an effective date of April 14^th, 2003.

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Name of Individual (Printed)                                         

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Signature of Individual

Date Signed _____  / ______  / ________