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HIPPA Notice

HIPAA Form

PRIVACY NOTICE 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. 

Effective Date: 01/01/2013 

Under Federal Law, How Might Your Protected Health Information Need to Be Used / Disclosed by Our Office for Treatment, Payment, or Health Care Operation Purposes?

Generally, your protected information may be used or disclosed by our clinic for treatment, payment, or specific health care operations. These three words or phrases are defined by Federal Law, 45 CFR s 164.501 and other regulations as follows: 

Treatment. Treatment means the provision, coordination, or management of health care and related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a patient; or the referral of a patient for health care from one health care provider to another. Payment. The activities undertaken by us to obtain or provide reimbursement for the provision of health care. Such activities include without limit determinations of eligibility or coverage (including coordination of benefits or the determination of cost sharing amounts); adjudication or subrogation of health benefit claims; billing, claims and practice management, collection activities, obtaining payment under a contract for reinsurance (including stop-loss insurance and excess of loss insurance), and related health care data processing, analysis and aggregation; provider accreditation; review of health care services with respect to medical necessity, coverage under a health plan, appropriateness of care, or justification of charges; and contacting your employer, or you through your employer, for reasons consistent with this paragraph including without limit to obtain current group benefits and effective dates. For the purposes of this Privacy Notice, activities undertaken to properly obtain or provide reimbursement may include without limit disclosures to accountants, attorneys, management consultants, financial consultants, organizations providing data aggregation and other like services, professional associations, and other similar entities, including their agents and subcontractors, where confidentiality is expressly agreed to or normally inferred. Such activities shall also include disclosures to state and federal agencies, officials, and employees for the purposes of enforcement of, and oversight over, payer responsibilities and obligations. Other Health Care Operations. 45 CFR s 164.501 and .520(b)(1)(iii) outline several other purposes for which our practice may use or disclose protected information. For example, our practice may use or disclose protected information for the purposes of (1) conducting training programs in which students, trainees, or practitioners in areas of health care learn under supervision to practice or improve their skills as health care providers, (2) providing appointment reminders to patients, (3) providing treatment alternatives or other health-related benefits and services that may be of interest to patients, and (4) contacting patients to raise funds. In addition to those operations listed above, our office may send you welcome cards as well as birthday cards to your attention by mail which may include the actual date of your birthday. Furthermore, for those patients who indicate who referred them to our clinic, our office may send you “Thank You” cards to the referring person. Disclosures to the Patient by Fax and E-mail; Disclosures Left on Voice Mail. Periodically, patients request that our clinic transmit protected information to them by means of fax or email, or leave messages on voice mail regarding such information. While we may request specific written authorization from you prior to disclosing protected information through such means, you hereby agree that by providing us with a fax number, email address, or phone number which includes voice mail, you are hereby consenting to disclosures through such means. Disclosures to “Personal Representatives” at the Patient’s Request Oftentimes, close relatives to our patients will request that we disclose protected health information to them on the patients’ behalf or at our patients’ request. You hereby agree that if the person you represent as your spouse contacts our clinic regarding your care, we may disclose protected information to them. Under Federal Law, How Might Your Protected Health Information Need to Be Used / Disclosed in Ways That Don’t Require Written Consent or Authorization? Under certain circumstances, law may require or permit our practice to make use of or to disclose your protected information without your consent or authorization. Such circumstances include: a) Uses and disclosures required by law. b) Uses and disclosures for public health activities. c) Disclosures about victims of abuse, neglect or domestic violence. d) Uses and disclosures for health oversight activities. e) Disclosures for judicial and administrative proceedings. f) Disclosures for law enforcement purposes. g) Uses and disclosures about decedents. h) Uses and disclosures for cadaveric organ, eye or tissue donation purposes. i) Uses and disclosures for research purposes. j) Uses and disclosures to avert a serious threat to health or safety. k) Use and disclosures for specialized government functions. l) Disclosures for workers' compensation. What Happens If Other Law is More Restrictive Than Federal Law? In the event other law becomes more restrictive than Federal Law with respect to uses and disclosures of your protected information, our practice will include descriptions of the more stringent requirements in this privacy notice. All Other Uses / Disclosures Require Your Written Authorization. All other uses and disclosures besides those listed herein and those which require an opportunity to agree or object (see 45 CFR 164.512) will only be made with your written authorization. Once such authorization is granted, you make revoke it at any time as provided by and subject to 45 CFR 164.508(b)(5). Your Rights and How to Exercise Those Rights Under Federal Law, you have the following rights. To exercise your rights, you will need to send a written request to the attention of the Privacy Officer of our clinic. You have the right to request restrictions on certain uses and disclosures of protected health information as provided by s 164.522(a). Please note however that under Federal Law, our clinic is not required to agree to a requested restriction. You have the right to receive confidential communications of protected health information as provided by and subject to 45 CFR s 164.522(b).You have the right to inspect and copy protected health information as provided by and subject to 45 CFR s 164.524.You have the right to amend protected health information as provided by and subject to 45 CFR s 164.526. You have the right to receive an accounting of disclosures of protected health information as provided by and subject to 45 CFR s 164.528.You have the right to obtain a copy of this privacy notice. Duties of Our Clinic Our clinic is required by law to maintain the privacy of your protected information and to provide you with notice of our legal duties and privacy practices concerning your protected information. Our clinic is required to abide by the terms of this privacy notice currently in effect. Our clinic reserves the right to change the terms of our notice and to make new notice provisions effective for all protected information that our clinic maintains. The revised notice will be made available at the front desk of our clinic for your inspection or copying. Complaints Our clinic welcomes any suggestions for amending our privacy practices. If you believe that your privacy rights have been violated, you may file a complaint with the Privacy Officer of our clinic and to the Secretary of Health and Human Services. To file a complaint with our Clinic’s Privacy Officer, simply request and complete a copy of our privacy complaint form and submit it to our Privacy Officer. No individual may be retaliated against for filing such a complaint. Contact Information or Further Information For more information, call our main office number and ask to speak with our Privacy Officer: Gabby Brule 972-424-2225.

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Prime Life Chiropractic

2504 K Avenue, Suite 500, Plano, TX 75074

Office Hours

Our Regular Schedule

Plano Office

Monday:

9:00 am-12:00 pm

2:00 pm-6:00 pm

Tuesday:

9:00 am-12:00 pm

2:00 pm-6:00 pm

Wednesday:

9:00 am-12:00 pm

2:00 pm-6:00 pm

Thursday:

9:00 am-12:00 pm

2:00 pm-6:00 pm

Friday:

9:00 am-1:00 pm

Saturday:

9:00 am-12:00 pm

Sunday:

Closed