THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE READ IT CAREFULLY.
NOTICE OF PRIVACY POLICY
Effective April 14, 2003
The following is the privacy policy (“Privacy Policy”) of Mink Chiropractic Center, LLC (“Covered “Entity”) as described in the Health Insurance Portability and Accountability Act of 1996 and
regulations promulgated thereunder, commonly known as HIPAA. HIPAA requires Covered Entity
by law to maintain the privacy of your personal health information and to provide you with
notice of Covered Entity’s legal duties and privacy policies with respect to your personal health
information. We are required by law to abide by the terms of this Privacy Notice.
Your Personal Health Information
We collect personal health information from you through treatment, payment and related
healthcare operations, the application and enrollment process, and/or healthcare providers or
health plans, or through other means, as applicable. Your personal health information that is
protected by law broadly includes any information, oral, written or recorded, that is created or
received by certain health care entities, including health care providers, such as physicians and
hospitals, as well as, health insurance companies or plans. The law specifically protects health
information that contains data, such as your name, address, social security number, and others,
that could be used to identify you as the individual patient who is associated with that health
information.
Uses or Disclosures of Your Personal Health Information
Generally, we may not use or disclose your personal health information without your permission.
Further, once your permission has been obtained, we must use or disclose your personal health
information in accordance with the specific terms that permission. The following are the
circumstances under which we are permitted by law to use or disclose your personal health
information.
Without Your Consent
Without your consent, we may use or disclose your personal health information in order to
provide you with services and the treatment you require or request, or to collect payment for
those services, and to conduct other related health care operations otherwise permitted or
required by law. Also, we are permitted to disclose your personal health information within and
among our workforce in order to accomplish these same purposes. However, even with your permission, we are still required to limit such uses or disclosures to the minimal amount of
personal health information that is reasonably required to provide those services or complete
those activities.
Examples of treatment activities include: (a) the provision, coordination, or management of
health care and related services by health care providers; (b) consultation between health care
providers relating to a patient; or (c) the referral of a patient for health care from one health
care provider to another.
Examples of payment activities include: (a) billing and collection activities and related data
processing; (b) actions by a health plan or insurer to obtain premiums or to determine or fulfill its
responsibilities for coverage and provision of benefits under its health plan or insurance
agreement, determinations of eligibility or coverage, adjudication or subrogation of health benefit
claims; (c) medical necessity and appropriateness of care reviews, utilization review activities;
and (d) disclosure to consumer reporting agencies of information relating to collection of
premiums or reimbursement.
Examples of health care operations include:
(a) development of clinical guidelines; (b) contacting patients with information about treatment
alternatives or communications in connection with case management or care coordination; (c)
reviewing the qualifications of and training health care professionals; (d) underwriting and
premium rating; (e) medical review, legal services, and auditing functions; and (f) general
administrative activities such as customer service and data analysis.
As Required By Law
We may use or disclose your personal health information to the extent that such use or
disclosure is required by law and the use or disclosure complies with and is limited to the
relevant requirements of such law. Examples of instances in which we are required to disclose
your personal health information include: (a) public health activities including, preventing or
controlling disease or other injury, public health surveillance or investigations, reporting adverse
events with respect to food or dietary supplements or product defects or problems to the Food
and Drug Administration, medical surveillance of the workplace or to evaluate whether the
individual has a work-related illness or injury in order to comply with Federal or state law; (b)
disclosures regarding victims of abuse, neglect, or domestic violence including, reporting to
social service or protective services agencies; (c) health oversight activities including, audits,
civil, administrative, or criminal investigations, inspections, licensure or disciplinary actions, or
civil, administrative, or criminal proceedings or actions, or other activities necessary for
appropriate oversight of government benefit programs; (d) judicial and administrative
proceedings in response to an order of a court or administrative tribunal, a warrant, subpoena,
discovery request, or other lawful process; (e) law enforcement purposes for the purpose of
identifying or locating a suspect, fugitive, material witness, or missing person, or reporting
crimes in emergencies, or reporting a death; (f) disclosures about decedents for purposes of
cadaveric donation of organs, eyes or tissue; (g) for research purposes under certain
conditions; (h) to avert a serious threat to health or safety; (i) military and veterans activities;
(j) national security and intelligence activities, protective services of the President and others;
(k) medical suitability determinations by entities that are components of the Department of
State; (l) correctional institutions and other law enforcement custodial situations; (m) covered entities that are government programs providing public benefits, and for workers’ compensation.
All Other Situations, With Your Specific Authorization
Except as otherwise permitted or required, as described above, we may not use or disclose your
personal health information without your written authorization. Further, we are required to use
or disclose your personal health information consistent with the terms of your authorization. You
may revoke your authorization to use or disclose any personal health information at any time,
except to the extent that we have taken action in reliance on such authorization, or, if you
provided the authorization as a condition of obtaining insurance coverage, other law provides
the insurer with the right to contest a claim under the policy.
Miscellaneous Activities, Notice
We may contact you to provide appointment reminders or information about treatment
alternatives or other health-related benefits and services that may be of interest to you. We
may contact you to raise funds for Covered Entity. If we are a group health plan or health
insurance issuer or HMO with respect to a group health plan, we may disclose your personal
health information to be sponsor of the plan.
Your Rights With Respect to Your Personal Health Information
Under HIPAA, you have certain rights with respect to your personal health information. The
following is a brief overview of your rights and our duties with respect to enforcing those rights.
Right To Request Restrictions On Use Or Disclosure
You have the right to request restrictions on certain uses and disclosures of your personal
health information about yourself. You may request restrictions on the following uses or
disclosures: to carry out treatment, payment, or healthcare operations; (b) disclosures to family
members, relatives, or close personal friends of personal health information directly relevant to
your care or payment related to your health care, or your location, general condition, or death;
(c) instances in which you are not present or your permission cannot practicably be obtained
due to your incapacity or an emergency circumstance; (d) permitting other persons to act on
your behalf to pick up filled prescriptions, medical supplies, X-rays, or other similar forms of
personal health information; or (e) disclosure to a public or private entity authorized by law or
by its charter to assist in disaster relief efforts.
While we are not required to agree to any requested restriction, if we agree to a restriction, we
are bound not to use or disclose your personal healthcare information in violation of such
restriction, except in certain emergency situations. We will not accept a request to restrict uses
or disclosures that are otherwise required by law.
Right To Receive Confidential Communications
You have the right to receive confidential communications of your personal health information.
We may require written requests. We may condition the provision of confidential communications
on you providing us with information as to how payment will be handled and specification of an
alternative address or other method of contact. We may require that a request contain a
statement that disclosure of all or a part of the information to which the request pertains could
endanger you. We may not require you to provide an explanation of the basis for your request
as a condition of providing communications to you on a confidential basis. We must permit you
to request and must accommodate reasonable requests by you to receive communications of
personal health information from us by alternative means or at alternative locations. If we are a
health care plan, we must permit you to request and must accommodate reasonable requests by
you to receive communications of personal health information from us by alternative means or at
alternative locations if you clearly state that the disclosure of all or part of that information
could endanger you.
Right To Inspect And Copy Your Personal Health Information
Your designated record set is a group of records we maintain that includes Medical records and
billing records about you, or enrollment, payment, claims adjudication, and case or medical
management records systems, as applicable. You have the right of access in order to inspect
and obtain a copy your personal health information contained in your designated record set,
except for (a) psychotherapy notes, (b) information complied in reasonable anticipation of, or for
use in, a civil, criminal, or administrative action or proceeding, and (c) health information
maintained by us to the extent to which the provision of access to you would be prohibited by
law. We may require written requests. We must provide you with access to your personal health
information in the form or format requested by you, if it is readily producible in such form or
format, or, if not, in a readable hard copy form or such other form or format. We may provide
you with a summary of the personal health information requested, in lieu of providing access to
the personal health information or may provide an explanation of the personal health information
to which access has been provided, if you agree in advance to such a summary or explanation
and agree to the fees imposed for such summary or explanation. We will provide you with access
as requested in a timely manner, including arranging with you a convenient time and place to
inspect or obtain copies of your personal health information or mailing a copy to you at your
request. We will discuss the scope, format, and other aspects of your request for access as
necessary to facilitate timely access. If you request a copy of your personal health information
or agree to a summary or explanation of such information, we may charge a reasonable
cost-based fee for copying, postage, if you request a mailing, and the costs of preparing an explanation or summary as agreed upon in advance. We reserve the right to deny you access to
and copies of certain personal health information as permitted or required by law. We will
reasonably attempt to accommodate any request for personal health information by, to the
extent possible, giving you access to other personal health information after excluding the
information as to which we have a ground to deny access. Upon denial of a request for access
or request for information, we will provide you with a written denial specifying the legal basis for
denial, a statement of your rights, and a description of how you may file a complaint with us. If
we do not maintain the information that is the subject of your request for access but we know
where the requested information is maintained, we will inform you of where to direct your
request for access.
Right To Amend Your Personal Health Information
You have the right to request that we amend your personal health information or a record about
you contained in your designated record set, for as long as the designated record set is
maintained by us. We have the right to deny your request for amendment, if: (a) we determine
that the information or record that is the subject of the request was not created by us, unless
you provide a reasonable basis to believe that the originator of the information is no longer
available to act on the requested amendment, (b) the information is not part of your designated
record set maintained by us, (c) the information is prohibited from inspection by law, or (d) the
information is accurate and complete. We may require that you submit written requests and
provide a reason to support the requested amendment. If we deny your request, we will provide
you with a written denial stating the basis of the denial, your right to submit a written
statement disagreeing with the denial, and a description of how you may file a complaint with us
or the Secretary of the U.S. Department of Health and Human Services (“DHHS”). This denial will
also include a notice that if you do not submit a statement of disagreement, you may request
that we include your request for amendment and the denial with any future disclosures of your
personal health information that is the subject of the requested amendment. Copies of all
requests, denials, and statements of disagreement will be included in your designated record
set. If we accept your request for amendment, we will make reasonable efforts to inform and
provide the amendment within a reasonable time to persons identified by you as having received
personal health information of yours prior to amendment and persons that we know have the
personal health information that is the subject of the amendment and that may have relied, or
could foreseeably rely, on such information to your detriment. All requests for amendment shall
be sent to our Privacy Officer, Denise Pennington, c/o Mink Chiropractic Center, LLC, 409 Northside Drive, Valdosta, GA 31602.
Right To Receive An Accounting Of Disclosures Of Your Personal Health Information
Beginning April 14, 2003, you have the right to receive a written accounting of all disclosures of
your personal health information that we have made within the six (6) year period immediately
preceding the date on which the accounting is requested. You may request an accounting of
disclosures for a period of time less than six (6) years from the date of the request. Such
disclosures will include the date of each disclosure, the name and, if known, the address of the
entity or person who received the information, a brief description of the information disclosed,
and a brief statement of the purpose and basis of the disclosure or, in lieu of such statement, a
copy of your written authorization or written request for disclosure pertaining to such
information. We are not required to provide accountings of disclosures for the following
purposes: (a) treatment, payment, and healthcare operations, (b) disclosures pursuant to your
authorization, (c) disclosures to you, (d) for a facility directory or to persons involved in your
care, (e) for national security or intelligence purposes, (f) to correctional institutions, and (g)
with respect to disclosures occurring prior to 4/14/03. We reserve our right to temporarily
suspend your right to receive an accounting of disclosures to health oversight agencies or law
enforcement officials, as required by law. We will provide the first accounting to you in any
twelve (12) month period without charge, but will impose a reasonable cost-based fee for
responding to each subsequent request for accounting within that same twelve (12) month
period. All requests for an accounting shall be sent to Mink Chiropractic Center, LLC, 409
Northside Drive, Valdosta, GA, 31602.
Complaints
You may file a complaint with us and with the Secretary of DHHS if you believe that your privacy
rights have been violated. You may submit your complaint in writing by mail or electronically to
our privacy officer, Denise Pennington, C/O Mink Chiropractic Center, LLC, 409 Northside Drive,
Valdosta, GA 31602, (229) 242-3042. A complaint must name the entity that is the subject of
the complaint and describe the acts or omissions believed to be in violation of the applicable
requirements of HIPAA or this Privacy Policy. A complaint must be received by us or filed with
the Secretary of DHHS within 180 days of when you knew or should have known that the act or
omission complained of occurred. You will not be retaliated against for filing any complaint.
Amendments to this Privacy Policy
We reserve the right to revise or amend this Privacy Policy at any time. These revisions or
amendments may be made effective for all personal health information we maintain even if
created or received prior to the effective date of the revision or amendment. We will provide you
with notice of any revisions or amendments to this Privacy Policy, or changes in the law
affecting this Privacy Notice, by mail or electronically within 60 days of the effective date of
such revision, amendment, or change.
On-going Access to Privacy Policy
We will provide you with a copy of the most recent version of this Privacy Policy at any time
upon your written request sent to Denise Pennington, c/o Mink Chiropractic Center, LLC, 409
Northside Drive, Valdosta, GA 31602 or at the following website address:
http://www.minkchiro.com. For any other requests or for further information regarding the
privacy of your personal health information, and for information regarding the filing of a complaint
with us, please contact our privacy officer Denise Pennington at the address, telephone number
listed above.