NOTICE OF PRIVACY PRACTICES

Los Altos Family Chiropractic Center
5050 El Camino Real, Ste. 200
Los Altos, Ca. 94022

THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

OUR PLEDGE TO YOU:   

The privacy of your health information is important to us.  We understand that your health information
is personal and we are committed to protecting it.  We create a record of the care and services you receive at our clinic.  We need this record to provide you with quality care and to comply with certain legal requirements.  This notice will tell you about the ways we may use and share health information about you.  It will also describe your rights and certain duties we have regarding the use and disclosure of health information.

USE AND DISCLOSURE OF YOUR HEALTH INFORMATION:

 
In the course of your care as a patient at Los Altos Family Chiropractic, we may use or disclose personal
and health related information about you in the following ways:

Treatment:  Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.  Your name, address, phone number and your health care records may be used to contact you regarding appointment matters (reminders, scheduling, follow-ups), or to provide information that may be of interest to you.  If you are not at home/work to receive a phone call regarding treatment or an appointment matter, a message may be left on your answering machine.   We normally provide information about your health care to you in person at the time you receive chiropractic care from us, but we may also mail information to you regarding your health care.

Payment:  Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, a PPO or your employer (if they are or may be responsible for the payment of your services), in order to bill and collect payment for the treatment and services provided.  We may also contact you by phone and a message may be left on your answering machine regarding an insurance or financial matter.  We may also mail you information about the status of your account.

Health Care Operations:  Your health care records may be disclosed for activities necessary to operate your health care plan including quality management, utilization review, anti-fraud, claims payment and provider credentialing activities.

This office utilizes an “open-door adjusting” environment for ongoing patient care.  “Open-door adjusting” involves being able to see and hear other patients receiving treatment.  Patients are within sight of one another when walking down hallways or from the waiting room, and some ongoing routine details of care are discussed within earshot of other patients and staff.  This environment is used for ongoing care and this is NOT the environment used for taking patient histories, providing examinations or presenting reports of findings.  These procedures are completed in a private, confidential setting.  The use of this format is intended to make your experience with our office more efficient and productive as well as to enhance your access to quality health care and health information.  If you choose not to be adjusted in an open-door adjusting environment, other arrangements will be made for you.









NOTICE OF PRIVACY PRACTICES

Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in the following circumstances:

    If we are providing health care services to you based on the orders of another health care provider.
    If we provide health care services to you in an emergency.
    If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so.
    If there are substantial barriers to communicating with you, but in our professional judgement we believe that you intend for us to provide care.
    If we are ordered by the courts or another appropriate agency.

AUTHORIZATION:

Any use or disclosure of your protected health information, other than as described in the examples outlined above, will only be made upon your written authorization, unless otherwise permitted or required by law.  In the event you authorize us to use or disclose your protected health information in ways other than those described above, you have the right to revoke that authorization at any time by delivering a written revocation statement, except to the extent that we have already disclosed the information, or are allowed by law to use the information to contest a claim or coverage.

YOUR RIGHTS:

    RIGHT TO REQUEST RESTRICTIONS ON USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION:

You have the right to request restrictions on the use and disclosure of your protected health information.  To request a restriction, please speak to Dr. Deborah Mosca or any staff member.
Please note that while you may request a restriction, we have a right to refuse that request.  If we accept your request, we will put the limits in writing and abide by them except in emergency situations.  You may not limit the uses and disclosures that we are legally required to make.

    RIGHT TO RECEIVE CONFIDENTIAL COMMUNICATIONS:

You have the right to receive confidential communications, including the right to direct where communications containing protected health information are sent.  For example, you may request that information be sent to your work address rather than your home address or via alternative means such as email rather than regular mail.  To verify or modify where or how you would like such communications sent, please speak to Dr. Deborah Mosca or any staff member.  We will accommodate all reasonable requests. Unless requested otherwise, we will direct mailings and telephone messages containing protected health information to the address and telephone number(s) we have on record for you.

    RIGHT TO INSPECT AND COPY PROTECTED HEALTH INFORMATION:

In most cases, you have the right to see and get copies of your protected health information for seven years from the date that the record was created.  If you want to see or get copies of your protected health information you must submit your request in writing to our office.  If we do not have your protected health information but know who does, we will tell you where you can get it.  We will respond to you within 30 days after receiving your written request.  In certain situations, we may deny your request.  If we do deny your request, we will tell you, in writing, the reasons for the denial and explain your right to have the denial reviewed.  If you request copies of your protected health information, we will charge you a reasonable copy fee, but will inform you of that fee in advance.  Instead of providing you with the protected health information you requested, we may provide you with a summary or explanation of the protected health information as long as you agree to the summary and any applicable charges in advance.




NOTICE OF PRIVACY PRACTICES

    RIGHT TO AMEND PROTECTED HEALTH INFORMATION:

If you believe that there is a mistake in your protected health information or that a piece of important information is missing, you have the right to request that we correct the existing information or add the missing information.  You must provide the request and your reasons in writing to our office.  We will respond within 30 days of receiving your request.  We may deny your request if the protected health information is (1) correct and complete, (2) not created by us, (3) not allowed to be disclosed, (4) not part of our records.  If we deny your request, we will provide you a written explanation.  You may respond with a statement of disagreement that will be added to the information you want changed.  If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.  

    RIGHT TO RECEIVE AN ACCOUNTING OF DISCLOSURES OF PROTECTED HEALTH INFORMATION:

You have a right to receive a list of all the times we, or our business associates shared your protected health information for purposes other than the treatment, payment, health care operations or other specified exceptions.  We will respond within 30 days of receiving your written request.  The accounting will include the date of the disclosure, to whom it was disclosed, and a brief statement of what information was disclosed and for what reasons.  We will provide the first accounting you request within a 12-month period at no charge. For additional accountings, we may charge you a fee for each additional request, but will inform you of that fee in advance.  To request an accounting of any such disclosures submit a request in writing to our office stating the time period for which you want the accounting.  The time period may not be longer than seven years and may not include dates before April 14, 2003.

    RIGHT TO GET A PAPER COPY OF THIS NOTICE:

You have the right to get a paper copy of this Notice at any time even if you previously agreed to receive an electronic copy.

    RIGHT TO FILE A COMPLAINT:

If you believe that we may have violated your privacy rights, please contact Dr. Deborah Mosca at 650-934-3700. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint.

OUR LEGAL DUTY:

We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein.  We are also required to provide you with this notice of our privacy practices with respect to your health information.  We are further required by law to abide by the terms of this notice while it is in effect.  We reserve the right to alter or amend the terms of this privacy notice.  If changes are made to our privacy notice, we will notify you in writing as soon as possible following the changes.  Any change in our privacy notice will apply for all of your health information in our files.  





03/03/03








NOTICE OF PRIVACY PRACTICES




This notice is effective as of April 14, 2003.  This notice, and any alterations or amendments made hereto, will expire seven years after the date upon which the record was created.  

My signature acknowledges that I have received a copy of this notice.



___________________________      ________________________    _______________
Name (printed)                                     Signature                                    Date


If you are a minor, or are being represented by another party

____________________________    ____________________________  ____________
Personal Representative (printed)         Personal Representative (signature)  Date


Description of the authority to act on behalf of the patient

03/03/03