BACK TO HEALTH
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.
Back to
Health 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.
Collection
and Use of Your Health Care Information
We may collect medical information, including a health
history, during your initial and subsequent visits. Some
of this medical
information may take the form of tests such as x-rays,
nerve conduction studies, MRIs, or other similar diagnostic
procedures.
This medical information will be used in the assessment
of your condition and in the need for health care or referral
purposes.
Some or
all of the medical information will be transferred to a computer
program for retrieval, storage, billing
and payment purposes. Medical information will be disclosed
to health and
disability insurers for the purpose of payment or reimbursement
of services. The medical information contained in the
medical
record will be stored by Back to Health for a period
of no less than six (6) years (or longer, if required
by state
law).
Disclosure
of Your Health Care Information
Treatment
We may disclose your health care information to other
healthcare professionals within our practice for the
purpose of treatment,
payment or healthcare operations. For example, on occasion,
it may be necessary to seek consultation regarding
your condition from other health care providers associated
with Back to
Health.
Further,
it is our policy to provide a substitute health care provider,
authorized by Back to Health to provide
assessment and/or treatment to our patients, without
advance notice,
in
the event of your primary health care provider’s
absence due to vacation, sickness, or other emergency
situation.
Payment
We may disclose your health information to our billing
company and/or your insurance provider for the
purpose of receiving
payment for 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 Back to Health
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.
Marketing or Reminder Appointments
We may contact you for marketing
or reminder purposes. 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.
Change
of Ownership
In the event that Back to Health
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. Such requests must be made in writing (ask our front desk
for the form). Please
be advised, however, that
Back to Health 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. Such requests must be made in writing (please ask our front desk for
the form), and must
be signed and dated. We
will then inform our billing company and all other appropriate Business Associates
of the alternate
method or location, and
flag your file to indicate same.
• You have the right to inspect and copy your health information.
• You have a right to request that Back to Health amend your
protected health information.
Please be advised, however, that Back to Health 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 Back to Health.
• You have a right to a paper copy of this Notice of Privacy
Practices at any time upon
request.
• Third party uses and disclosures other than for purposes of
treatment, payment or health
care operations, will be made only with your written authorization, and you may
revoke such
authorization as provided
by law.
• Back to Health will make every effort possible to protect the
privacy and confidentiality
of all health information of its patients against inappropriate or unauthorized
use and disclosure,
as required by law.
• Back to Health’s procedure is to inform you of future
changes and revisions to
the Notice of Privacy Practices, within 60 days of a material revision to the
notice requirements.
Changes
to this Notice of Privacy Practices
Back to Health 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, Back to
Health is required
by law to comply with
this Notice.
Back to Health 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: Leigh
Dundas by calling
this office at (714)
965-5145. If Leigh
Dundas
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 Back to
Health has handled
your health
information
should
be
directed
to Leigh Dundas by
calling this office at (714)
965-5145 If
Leigh Dundas
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 Back
to Health 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
________________________________________________
Patient’s Name (print)
________________________________________________
______________
Patient’s Signature Date
________________________________________________
______________
Authorized
Facility Signature
Date
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