THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
In the course of your care as a patient at Madison Avenue Chiropractic
Center, we may use or disclose personal and health related information
about you in the following ways:
*Your personal health information, including your clinical records, may
be disclosed to another health care provider or hospital if it is
necessary to refer you for further diagnosis, assessment or treatment.
*Your health care records as well as your billing records may be
disclosed to another party, such as an insurance carrier, an HMO, a PPO,
or your employer (if they are or may responsible for the payment of your
*Your name, address, phone number, and your health care records may be
used to contact you regarding appointment reminders, to provide
information about alternatives to your present care, or to other health
related information that may be of interest to you.
If you are not at home to receive an appointment reminder, a message may
be left on your answering machine. Further, you have the right to
inspect or obtain a copy of the information we will use for these
purposes. You also have the right to refuse to provide authorization for
this office to contact you regarding these matters. If you do not
provide us with this authorization it will not affect the care provided
to you or the reimbursement avenues associated with your care.
Under federal law, we are also permitted or required to use or disclose
your health information without your consent or authorization in the
*If we are providing health care services to you based on the orders of
another health care provider.
*If we provide health care services to you in an emergency.
*If we are required by law to provide care to you and we are unable to
obtain your consent after attempting to do so.
*If there are substantial barriers to communicating with you, but in our
professional judgment we believe that you intend for us to provide care.
*If we are ordered by the courts or another appropriate agency
Any use or disclosure of your protected health information, other than
as described in the examples outlined above, will only be made upon your
We normally provide information about your health care to you in person
at the time you receive chiropractic care from us. We may also mail
information to you regarding your health care or about the status of
your account. If you would like to receive this information at an
address other than your home or, if you would like the information in a
different form, please advise us in writing as to your preferences.
You have the right to inspect and/or copy your health information for
seven years from the date that the record was created or for as long as
the information remains in our files. In addition, you have the right to
request an amendment to your health information. Requests to inspect,
copy or amend your health related information should be provided to us
We are required by state and federal law to maintain the privacy of your
patient file and the health protected health information therein. We are
also required to provide you with this notice of our privacy practices
with respect to your health information.
We are further required by law to abide by the terms of this notice
while it is in effect. We reserve the right to alter or amend the terms
of this privacy notice. If changes are made to our privacy notice, we
will notify you in writing as soon as possible following the changes.
Any change in our privacy notice will apply for all of your health
information in our files. Information that we use or disclose based on
this privacy notice may be subject to re-disclosure by the person. If
you have a complaint regarding our privacy notice, our privacy practices
or any aspect of our privacy activities you should direct your complaint
to Dr. Smatt. If you would like further information about our
privacy policies and practices please contact Dr. Smatt, or
persons to whom we provide the information and may no longer be
protected by the federal privacy rules.
This notice is effective as of April 14, 2003. This notice, and any
alterations or amendments made hereto will expire seven years after the
date upon which the record was created. My signature acknowledges that I
have received a copy of this notice.
____________________________ __________________________ ________
Name (Printed Please) Signature Date
If you are a minor, or if you are being represented by another party
Personal Representative Printed
Personal Representative Signature
Description of the authority to act on behalf of the patient.