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.
Westwood Village Chiropractic® is required, by law, to maintain the privacy and confidentiality of your protected health information (PHI) and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information (PHI).
Disclosure of Your Health Care Information
Treatment - We may disclose your PHI to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations.
Payment - We may disclose your PHI to your insurance provider for the purpose of payment or health care operations.
Workers’ Compensation - We may disclose your PHI as necessary to comply with State Workers’ Compensation Laws.
Emergencies - We may disclose your PHI 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 PHI 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 PHI in the course of any administrative or judicial proceeding.
Law Enforcement - We may disclose your PHI 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 PHI to coroners or medical examiners. We may make relevant disclosures to the deceased’s family and friends under essentially the same circumstances that such disclosures were permitted when the patient was alive; that is, when these individuals were involved in providing care or payment for care and we are unaware of any expressed preference to the contrary.
Organ Donation - We may disclose your PHI to organizations involved in procuring, banking, or transplanting organs and tissues.
Fundraising – This office does not participate in fundraising.
Research - We may disclose your PHI to researchers conducting research that has been approved by an Institutional Review Board. If researchers are allowed access to information that identifies who you are, we will ask for your permission.
Public Safety - It may be necessary to disclose your PHI to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.
Specialized Government - Agencies - We may disclose your PHI for military, national security, prisoner and government benefits purposes.
Change of Ownership - In the event that Westwood Village Chiropractic® is sold or merged with another organization, your PHI/records will become the property of the new owner.
– This Practice may use and disclose your PHI to one or more of its business associates if the Practice obtains satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI. A business associate is an entity that assists the Practice in undertaking some essential function, such as billing company that assists the office in submitting claims for payment to insurance companies. Your Health Information Rights
- You have the right to request restrictions on certain uses and disclosures of your PHI. Please be advised, however, that Westwood Village Chiropractic® is not required to agree to the restriction that you requested.
- You have the right to have your PHI received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.
- You have the right to inspect and request copies of your PHI.
To inspect or copy your information, you may either complete an Authorization to Release/Obtain Information form or write a letter of request, stating the type of information to be released, the date(s) of service being requested, the purpose of the request, and whether you wish to review the record or receive copies of the requested information in your preferred format. We will abide by your request in the format you have requested, if we are able to do so. If we cannot provide your records to you in the requested format, we will attempt to provide them in an alternative format that you agree to. You may also request that your records be sent to another person that you have designated in writing. Direct this request to the Practice’s Privacy Officer. You may be charged a fee for the cost of copying, mailing or other expenses related with your request.
We may deny your request to inspect and copy information in a few limited situations. If your request is denied, you may ask for our decision to be reviewed. The practice will choose a licensed health care professional to review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of that review.
- You have the right to request that we restrict the uses or disclosures of your information for treatment, payment or healthcare operations. You may also request that we limit the information we share about you with a relative or friend of yours. You also have the right to restrict disclosure of information to your commercial health insurance plan regarding services or products that you paid for in full, out-of-pocket and we will abide by that request unless we are legally obligated to do so.
- You have a right to request that Westwood Village Chiropractic® amend your PHI. Please be advised, however, that Westwood Village Chiropractic® is not required to agree to amend your PHI. If your request to amend your PHI has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.
- You have a right to receive an accounting of disclosures of your PHI made by Westwood Village Chiropractic®.
- You have a right to a paper copy of this Notice of Privacy Practices, even if you have agreed to receive this Notice electronically. You may request a paper copy of this Notice at any time.
The following uses and/or disclosures specifically require your express written permission:Marketing Purposes
– Westwood Village Chiropractic® does not participate in marketingSale of Health Information
– Westwood Village Chiropractic® does not participate in selling a patient’s PHI.
We must disclose that we will not sell your PHI without your written authorization. If you do authorize such a sale, the authorization will disclose that we will receive compensation for any information that you have authorized us to sell. You have the right to revoke the authorization at any time, which will halt any future sale.
Uses and/or disclosures other than those described in this Notice will be made only with your written authorization. If you do authorize a use and/or disclosure, you have the right to revoke that authorization at any time by submitting a revocation in writing to our Privacy Officer. However, revocation cannot be retroactive and will only impact uses and/or disclosures after the date of revocation.
Changes to this Notice of Privacy Practices
Westwood Village Chiropractic® 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, Westwood Village Chiropractic® is required by law to comply with this Notice.
Westwood Village Chiropractic® 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: Karen Nishimoto by calling this office at 310-475-0444. If Karen Nishimoto is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.
You will be notified immediately if we receive information that there has been a breach involving your personal health information.
Complaints about your Privacy rights or how Westwood Village Chiropractic® has handled your health information should be directed to Karen Nishimoto by calling this office at 310-475-0444
. If Karen Nishimoto is not available, you may make an appointment for a personal conference in person or by telephone within 2 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 Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
This notice is effective as of 4/14/03.
Patient/Guardian Signature Date
Authorized Facility Signature Date