| CHIROPRACTIC CARE OF BEDMINSTER, P.C. DR. NICK MAVROSTOMOS, D.C. CKTI
Patient Policy 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. Chiropractic Care of Bedminster, P.C. is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information. Disclosure of Your Health Care Information Treatment We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. (example) “On occasion, it may be necessary to seek consultation regarding your condition from other health care providers associated with Chiropractic Care of Bedminster, P.C..” “It is our policy to provide a substitute health care provider, authorized by Chiropractic Care of Bedminster, P.C. to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary health care provider’s absence due to vacation, sickness, or other emergency situation.” Payment We may disclose your health information to your insurance provider for the purpose of payment or health care operations. (example) “As a courtesy to our patients, with the insurance company with which our office accepts assignment (payment) we will submit an itemized billing statement to your insurance carrier for the purpose of payment to Chiropractic Care of Bedminster, P.C. for health care services rendered. If you pay for your health care services personally, we will, as a courtesy, provide an itemized billing to your insurance carrier for the purpose of reimbursement to you. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the health care services received.”
Workers’ Compensation Emergencies We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death. Public Health As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure. Judicial and Administrative Proceedings. We may disclose your health information in the course of any administrative or judicial proceeding. Law Enforcement. We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes. Deceased Persons. We may disclose your health information to coroners or medical examiners. Organ Donation. We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues. Research. We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board. Public Safety. It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public. Specialized Government Agencies. We may disclose your health information for military, national security, prisoner and government benefits purposes. Marketing. We may contact you for marketing purposes or fundraising purposes, as described below: (example) “As a courtesy to our patients, it is our policy to call your home on the evening prior to your scheduled appointment to remind you of your appointment time. If you are not at home, we leave a reminder message on your answering machine or with the person answering the phone. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment.” “It is our practice to participate in charitable events to raise awareness, food donations, gifts, money, etc. During these times, we may send you a letter, post card, invitation or call your home to invite you to participate in the charitable activity. We will provide you with information about the type of activity, the dates and times, and request your participation in such an event. It is not our policy to disclose any personal health information about your condition for the purpose of Chiropractic Care of Bedminster, P.C. sponsored fund-raising events.” Change of Ownership. In the event that Chiropractic Care of Bedminster, P.C. is sold or merged with another organization, your health information/record will become the property of the new owner. Your Health Information RightsYou have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that Chiropractic Care of Bedminster, P.C. is not required to agree to the restriction that you requested.
You have the right to have your health
information received or communicated through an alternative method or sent
to an alternative location other You have the right to inspect and copy your health information. You have a right to request that Chiropractic Care of Bedminster, P.C. amend your protected health information. Please be advised, however, that Chiropractic Care of Bedminster, P.C. is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s)and information about how you can disagree with the denial. You have a right to receive an accounting of disclosures of your protected health information made by Chiropractic Care of Bedminster, P.C.. You have a right to a paper copy of this Notice of Privacy Practices at any time upon request. Changes to this Notice of Privacy Practices Chiropractic Care of Bedminster, P.C. reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, Chiropractic Care of Bedminster, P.C. is required by law to comply with this Notice. Chiropractic Care of Bedminster, P.C. is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: Nick Mavrostomos, D.C. by calling this office at 9082342317. If Nick Mavrostomos, D.C. is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days. Complaints Complaints about your Privacy rights, or how Chiropractic Care of Bedminster, P.C. has handled your health information should be directed to Nick Mavrostomos, D.C. by calling this office at 9082342317 If Nick Mavrostomos, D.C. is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days. Collections: All patients who fail to take responsibility for their treatment and whose accounts are delinquent will be sent to a collection agency. You will receive standard letters from Chiropractic Care of Bedminster, P.C. the last one being Certified/Return Receipt. If payment or acceptable payment plans are not met, the collection agencies fees as well as office fees will be added to the outstanding balance. Any information you provided to the office which is required by the “agent” will be forwarded. If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:
DHHS, Office of Civil Rights This notice is effective as of ______/______/_______ I have read the Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide Chiropractic Care of Bedminster, P.C. with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice ________________________________________________ Patient’s Name (print) ________________________________________________ ______________ Patient’s Signature Date ________________________________________________ ______________ Authorized Facility
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