Notice of Privacy for: Patient's Protected Health Information

This notice describes how health care information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

This office abides by the terms describe in this policy: This office uses and discloses your protected health care information for the following reasons: To share with other treating health care providers regarding your health care. To submit to insurance companies or Worker's Compensation to verify that treatment has been rendered. To determine patient's benefits in a health care plan. Releasing information required by State or Federal Public Health Law. To assist in overcoming a language barrier when caring for a patient. Business associates providing written assurances for your privacy have been attained. Emergency situations Abuse, neglect, or domestic violence Appointment reminders to household members or answering machines Sign-In logs may be disclosed to verify office visits. To send out birthday cards and newsletters Any other uses or disclosures will only be made with your specific written prior authorizations. You have the right to: Revoke authorization, in writing at any time by specifying what you want restricted and to whom. Speak to our privacy officer who is Dr. Bergman and can be reached at Marshall Chiropractic regarding privacy issues. Inspect, copy and amend your protected health information and amend it as allowed by law. Obtain an accounting of disclosures of your protected health information. To render a complaint to our privacy officer This office reserves the right to change the terms of this notice and make new notice provisions for all protected health information that it maintains. Patients may also get an updated copy upon request at any time by asking the staff. I acknowledge that I have received and reviewed this notice with full understanding.

 

Name of patient _________________________

Signature of Patient Legal Representative ____________________________________

Date ____________