Notice of privacy practices
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.
When it comes to
your health information, you have certain rights. This section
explains your rights and some of our responsibilities to help you.
You have the right to:
Get an electronic or paper copy of your medical record
You can ask to see or get an electronic or paper copy of
your medical record and other health information we have about you. Ask us how
to do this.
We will provide a copy or a summary of your health
information, usually within 30 days of your request. We may charge a
reasonable, cost-based fee.
Ask us to correct your medical record
You can ask us to correct health information about you
that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in
writing within 60 days.
You can ask us to contact you in a specific way about your
medical information (for example, home or office phone) or to send your medical
information to a different address.
We will say, “yes” to all reasonable requests.
us to limit what we use or share
You can ask us not to use or share certain health
information for treatment, payment, or our operations. We are not required to
agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or healthcare item out-of-pocket
in full, you can ask us not to share that information for the purpose of
payment or our operations with your health insurer. We will say “yes” unless a
law requires us to share that information.
list of those with whom we’ve shared information
You can ask for a list (accounting) of the times we’ve
shared (disclosed) your health information, for up to six years prior to the
date you ask, who we shared it with, and why.
We will include all the disclosures except for those about
treatment, payment, and healthcare operations, and certain other disclosures
(such as any you asked us to make). We’ll provide one accounting a year for
free but will charge a reasonable, cost-based fee if you ask for another one
within 12 months.
copy of this privacy notice
You can ask for a paper copy of this
notice at any time, even if you have agreed to receive the notice
electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
If you have given someone
medical power of attorney or if someone is your legal guardian, that person can
exercise your rights and make choices about your health information. We will
make sure the person has this authority and can act for you before we take any
a complaint if you feel your rights are violated
You can file a complaint with us if
you feel we have violated your rights by contacting our Privacy Officer.
To file a complaint with our organization, please submit
your request in writing to the Privacy Officer (insert name of officer), (insert address, phone number, email) (insert
city, state, zip).
You can file a complaint with the U.S. Department of
Health and Human Services’ Office for Civil Rights by sending a letter to 200
Independence Avenue, S.W., Washington, D.C. 20201, by calling 877-696-6775, or
We will not retaliate against you for filing a complaint.
health information, you can tell us your choices about what we share. If you have a
clear preference for how we share your information in the situations described
below, contact us. Tell us what you want us to do, and we will follow your
In these cases, you have both the right and
choice to tell us to:
Share information with your family, close friends, or
others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory
If you are not able to tell
us your preference - for example, if you are unconscious, we may share your
information if we believe it is in your best interest to do so. We may also
share your information when needed to lessen a serious and imminent threat to
health or safety.
In these following cases, we never share your information unless you
give us written permission:
of your protected health information
sharing of psychotherapy notes
In the case of fundraising:
may contact you for fundraising efforts, but you can tell us not to contact you
again. We will honor your request to not contact you again.
Confidentiality of Alcohol and Drug
The confidentiality of alcohol and drug abuse
patient records maintained by us is protected by Federal law and regulations,
including those regulations contained in 42 CFR Part 2. Generally, we may not
say to a person outside of our facility that you are a patient of the treatment
center, or disclose any information identifying you as an alcohol or drug
consent in writing;
disclosure is allowed by a court order; or
disclosure is made to medical personnel in a medical emergency or to qualified
personnel for research, audit, or program evaluation.
of the Federal law and regulations by our facility is a crime. Suspected
violations may be reported to appropriate authorities in accordance with
law and regulations do not protect any information about a crime committed by
you either at our facility or against any person who works for the facility or
about any threat to commit such a crime.
laws and regulations do not protect any information about suspected child abuse
or neglect from being reported under State law to appropriate State or local
See 42 U.S.C. 290dd-3 and
42 U.S.C. 290ee-3 for Federal laws and 42 CFR part 2 for Federal regulations.
Our Uses and
We typically use
or share your health information in the following ways:
can use your health information and share it with other professionals who are
Example: A doctor treating you for an injury asks
another doctor about your overall health condition.
can use and share your health information to run our practice, improve your
care, and contact you when necessary.
Example: We use health
information about you to manage your treatment and services.
for your services
We can use and share your health information to bill and get
payment from health plans or other entities.
Example: We give information
about you to your health insurance plan so it will pay for your services.
How else can we
use or share your health information?
We are allowed or required to share your information in other ways
– usually in ways that contribute to the public good, such as public health and
research. We have to meet many conditions in the law before we can share your
information for these purposes.
Help with public
health and safety issues
We can share health information about you for
certain situations such as:
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health
We can use or share your information for health
As Required by law
federal, state, and/or local law requires a use or disclosure of your PHI, we
may use or disclose your PHI to the extent that the use or disclosure complies
with such law and is limited to the requirements of such law. If two or more
laws or regulations governing the same use or disclosure conflict with each
other, we will comply with the more restrictive laws or regulations. An example
of when we may be required to share information under federal law is when the
Secretary of the Department of Health and Human Services (DHHS) requires that
we disclose such information to DHHS. The Secretary of DHHS may require that we
disclose such information to it to determine whether we are complying with
HIPAA or other federal law.
to organ and tissue donation requests
We can share health information about you with organ procurement
with a medical examiner or funeral director
We can share health
information with a coroner, medical examiner, or funeral director when an
compensation, law enforcement, and other government requests
We can use or share health information about you:
For workers’ compensation claims
For law enforcement purposes or with a law enforcement
With health oversight agencies for activities authorized
For special government functions such as military,
national security, and presidential protective services
Respond to lawsuits
and legal actions
We can share health information about you in
response to a court or administrative order, or in response to a subpoena.
We are required by law to maintain the privacy and
security of your protected health information.
We will let you know promptly if a breach occurs that may
have compromised the privacy or security of your information.
We must follow the duties and privacy practices described
in this notice and give you a copy of it.
We will not use or share your information other than as
described here unless you tell us we can in writing. If you tell us we can, you
may change your mind at any time. Let us know in writing if you change your
to the Terms of this Notice
change the terms of this notice, and the changes will apply to all information
we have about you. The new notice will be available upon request, on our website, and we will mail a copy to you.
Effective Date of
Notice : 9/15/2021
signature will be retained on the form labeled __ Acknowledgment of receipt of
Notice of Privacy Practices__ in regard to receipt of this notice upon request.
This notice is posted in the office at the front desk, as well as on the
website for the practice at www.kauffmanchiropractic.com for ease of