ADDITIONAL INFORMATION REGARDING THE RELEASE OF PROTECTED HEALTH INFORMATION (PHI)[Droessler Chiropractic] recognizes the patient’s right to confidentiality of protected health information in accordance with the federal privacy rule and Wisconsin law. Patients should be aware of the following information when requesting the release of protected health information:
Right to Refuse to Sign this Authorization
A patient has the right to refuse to sign this authorization form and [Droessler Chiropractic] will not condition treatment or payment of claims upon the provision that the patient sign this authorization form.
Right to Inspect or Copy the Information to be Used or Disclosed
A patient has the right to inspect or obtain a copy of the protected health information to be used or disclosed by signing this authorization form and may arrange a time to do so by contacting the medical records department.
Right to Receive a Copy of this Authorization
A patient has the right to request a copy of the signed authorization.
Right to Revoke Authorization
A patient has the right to revoke an authorization at any time by giving a written notice of revocation to the Privacy Officer listed below. Revocation of this authorization will not apply to information that has been released in compliance with this authorization prior to the receipt of the written notice of revocation. The revocation will not apply to the patient’s insurance company when the law provides the insurer with the right to contest a claim under the patient’s policy.
Redisclosure of Information by Recipient
Any disclosure of protected health information carries with it the potential for an unauthorized redisclosure. If the person(s) and/or organization listed in Section 3 are not health care providers, health plans or health care clearinghouses subject to the federal privacy rule, the protected health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards and may be redisclosed without obtaining my authorization.
Multiple Releases of Information
A patient may request multiple releases of information described on the authorization form (Section 6). However, all releases based on this form are limited to records dated up to and including the date of the patient’s signature unless otherwise specified. A new authorization is necessary for release of information related to care provided after the date of the patient’s signature, unless the authorization specifies release of future records of a specific test or a specific clinic appointment.
If [NAME OF COVERED ENTITY] uses this authorization for marketing activities, the patient will be informed if [NAME OF COVERED ENTITY] receives any direct or indirect payment in connection with the use or disclosure of the patient’s information.
HIV Test Results
A patient’s HIV test results may be released without authorization to persons/organizations that have access under State law and a list of those persons/organizations is available upon request.
Who May Sign Authorization
Wisconsin Statutes recognize the need for informed consent. Generally, all patients 18 years of age and over must sign for release of their own medical records unless the following conditions apply:
• The patient is incompetent.
• The patient is disabled and cannot sign the form.
• The patient is deceased. (A surviving spouse or personal representative of the estate may sign. If no such person exists, then an adult member of the immediate family may sign).
Patients less than 18 years of age must sign for release of their medical records when:
• The patient is 14 years of age or older and the records involve mental health treatment or developmental disabilities (parents retain the right to access this information)
• The patient is 14 years of age or older and the records involve HIV test results
• The patient is 12 years of age or older and the records involve alcoholism or drug dependence
• The patient is an emancipated minor who is married or in the military
• The patient’s records for release include abortion procedure.
All persons signing for release of protected health information on behalf of a patient must state their relationship to the patient and provide proof of their legal authority to act on behalf of the patient (Section 7).
Privacy Officer: William E. Droessler, D.C.; 6000 Monona Drive Suite 201, Monona, Wi. 53716 608-249-4010]
NOTE TO RECIPIENT OF INFORMATION: This protected health information has been disclosed according to federal and state privacy rules. Unless you have further authorization, these rules may prohibit you from redisclosing this information without the specific written consent of the patient or the patient’s legal represent[Droessler Chiropractic] NOTICE OF PRIVACY PRACTICES
YOUR INFORMATION. YOUR RIGHTS. OUR RESPONSIBILITIES.
This Notice is effective September 23, 2013 and describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Any questions regarding this Notice should be directed to [William E. Droessler, D.C.] Privacy Officer, , who can be reached at [6000 Monona Dr, Suite 201, Monona, Wi 53716; 608-249-4010; email email@example.com
You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
OUR USES AND DISCLOSURES
We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
- 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.
- Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say “yes” to all reasonable requests.
- Ask 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 health care 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.
- Get a list of those with whom we’ve shared information
- You can ask for a list (accounting) of the times we’ve shared your health information for 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 health care 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.
- Get a 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 action.
- File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting the Privacy Officer identified on page 1.
- 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, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
For certain 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, talk to us. Tell us what you want us to do, and we will follow your instructions.
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 go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.
OUR USES AND DISCLOSURES
How do we typically use or share your health information? We typically use or share your health information in the following ways.
- Treat you
- We can use your health information and share it with other professionals who are treating you.
- Example: A doctor treating you for an injury asks another doctor about your overall health condition.
- Run our organization
- We 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.
- Bill 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. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• 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 or safety
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ 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 official
• With health oversight agencies for activities authorized by law
• 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 mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
CHANGES TO THE TERMS OF THIS NOTICE
We can 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, in our office, and on our web site.
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE
By signing this form, you acknowledge that [Name of Covered Entity] has given you a copy of its Privacy Notice, which explains how your health information will be handled in various situations. We must try to have you sign this form on your first date of service with us. This includes the situation where your first date of service occurred electronically.
If your first date of service with us was due to an emergency, we must try to give you this notice and get your signature acknowledging receipt of this notice as soon as we can after the emergency.
I have received [Droessler Chiropractic]’s Privacy Notice.
Print Name Unique Identifier
Patient’s Signature Date
For office use only:
Medical Record #:
Date of Admission:
Filed electronically: ___Yes ___No
Forward completed form to HIS to file in patient’s chart: ____Yes ___No
[Name of Covered Entity] staff should complete if Acknowledgement Form is not signed:
1. Does patient have a copy of the Privacy Notice? [ ] Yes [ ] No
2. If you answered “No” above, please explain why the patient did not sign an acknowledgement form and [Name of Covered Entity] efforts in trying to obtain the patient’s signature (check all that apply):
[ ] Patient Unable to Comprehend [ ] Patient/Legal Representative Left before Signature Obtained
[ ] Patient Communication Barrier [ ] Emergency Admission/Patient Not Present for Registration
[ ] Legal Representative not Available [ ] Patient bypassed Registration – Not Available
[ ] Other:
3. Completed by:
Workforce Member Signature Title Date