HIPAA Privacy & Good Faith Estimate

Our Legal Duty

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice explaining our privacy practices, our legal duties, and your rights concerning your health. We must follow the privacy practices as described in this Notice while it is in effect. This Notice (which is a revision of our original Notice dated November 1, 2002) takes effect May 1, 2003 and will remain in effect until we change or replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us by using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION 

We may use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider with the intention of providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services provided to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorizations to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you as described in the Patient Rights section of this Notice. We will also disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you give us permission to do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in you healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up your supplements, medical supplies, x-rays, or other similar forms of health information.

Required by Law: We may use or disclose your health information when we are required to do so by law.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose health information required for lawful intelligence, counterintelligence, and other national security activities to authorized federal officials. We may disclose to correctional institution or law enforcement official having custody of protected health information of inmate or patient under certain circumstances.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

Appointment Reminders/ Follow Up Procedures: By signing this Notice, you are authorizing that we may use or disclose your health information to provide you with appointment reminders and/or to follow-up on your treatment plan or health status (such as telephone calls, voicemail messages, letters and e-mail.)

Marketing Health-Related Services: By signing this Notice, you are authorizing that we may use your health information for marketing communications for this health facility only. We will not disclose or share your health information with any outside facilities for purposes of marketing.

Patient Rights 

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies we will charge the following fees: $8.40 per request or $.45 per record page. Postage is extra. All fees must be paid BEFORE releasing any information.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to abide by your additional restrictions in an emergency situation.

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make this request in writing.) Your request must specify the alternative means or location, and provide a satisfactory explanation of how payments will be handled under the alternative means or location.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing and must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS 

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made regarding the disclosure of your health information, you may file a complaint with our Privacy Officer. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide their address upon request.

We support your right to the privacy of your health information. We respect your right to file a complaint and will not take any action against you if you do so. While you may make an oral complaint at any time, written comments should be sent to us at the address listed below.

To Contact Us:

Howard Chiropractic Clinic, SC
721 Cardinal Lane, Suite 100
Green Bay, WI 54313-6813

Privacy Officer: Vanessa Sanchez

(920) 434-2221

“Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act 

Instructions Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges. 

Good Faith Estimate Form 

 Disclaimer:   

• The good faith estimate shows you the costs of items and services that are reasonably expected for your health care needs for an item or service. However, this estimate may not include new areas of treatment, new injuries and/or changes in therapy. The estimate is based on the information known at the time the estimate was created.
• The good faith estimate does not include any unknown or unexpected costs that may arise during treatment.   
• You could be charged more if special circumstances occur.   
• Due to a staff shortage our office may not be able to verify your chiropractic benefits for up to 6 days from your first visit per our office policy.