Westwood Village Chiropractic®
NOTICE OF PRIVACY PRACTICES

As a courtesy to our patients, we will submit an itemized billing statement to your insurance carrier for the purpose of payment to Westwood Village Chiropractic® 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.

Research.
We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.

Public Safety.
It may be necessary to disclose your health information 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 health information 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 health information/record will become the property of the new owner.

Your Health Information Rights

• You have the right to request restrictions on certain uses and disclosures of your health information. 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 health information 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 copy your health information.
• You have a right to request that Westwood Village Chiropractic® amend your protected health information. Please be advised, however, that Westwood Village Chiropractic® is not required to agree to amend your protected health information. If your request to amend your health information 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 protected health information made by Westwood Village Chiropractic®.
• You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

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 310-208-7725. If Karen Nishimoto is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

Complaints
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 310-208-7725 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 ______/______/_______

I have read the Privacy Notice and understand my rights contained in the notice.

By way of my signature, I provide Westwood Village Chiropractic® with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice

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Patient's Name (print)

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Patient's Signature Date

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Authorized Facility Signature Date