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
Our offices are 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. This notice pertains to the business entities Dynamic Life, PLLC, hereafter referred to as Dynamic Life Chiropractic.
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 treatment from other health care providers associated with Dynamic Life Chiropractic.
- It is our policy to provide a substitute health care provider, authorized by Dynamic Life Chiropractic 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 emergency.
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, we will submit an itemized statement to your insurance center for the purpose of payment to Dynamic Life Chiropractic for health care services rendered. If you pay for your health care services personally we will, as a courtesy to you, 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 may describe the health care services received.
SMS Text Messaging
If you consent to receive SMS from Dynamic Life Chiropractic, you agree to receive appointment and in-house marketing related SMS from us.
We will not share your opt-in to an SMS campaign with any third party for purposes unrelated to providing you with the services of that campaign. We may share your Personal Data, including your SMS opt-in or consent status, with third parties that help us provide our messaging services, including but not limited to platform providers, phone companies, and any other vendors who assist us in the delivery of text messages. All of the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.
Worker’s Compensation
We may disclose your health information as necessary to comply with State Workers Compensation Laws.
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 your death.
Public Health
As required by law, we may disclose your health information to public health authorities for the 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 infectious 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 law enforcement officials for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order of 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.
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 you prior to your initial scheduled appointment to remind you of your appointment time. If you are not home, we will leave a reminder message on your voicemail 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, etc. During these times, we may need to send you a letter, post card 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 Dynamic Life Chiropractic sponsored fund-raising events.
Change of Ownership
In the event that Dynamic Life Chiropractic is sold or merged with another organization, your health information will become the property of the new owner.
Your Health Information Rights
- You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that Dynamic Life Chiropractic is not required to agree to the restriction 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 than the usual method of communication or delivery, upon your request.
- You have the right to inspect and receive a copy of your health information.
- You have the right to request that Dynamic Life Chiropractic amend your protected health information. Please be advised, however, that Dynamic Life Chiropractic 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 the right to receive an accounting of disclosures of your protected health information made by Dynamic Life Chiropractic
- You have the right to a paper copy of this Notice of Privacy Practices at any time upon request.
Changes to this Notice of Privacy Practices
Dynamic Life Chiropractic 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 the information that it maintains. Until such an amendment is made, Dynamic Life Chiropractic is required by law to comply with this Notice.
Dynamic Life Chiropractic 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 us at (248) 593-0843.
Complaints
Complaints about your Privacy rights or how Dynamic Life Chiropractic has handled your health information should be directed to Daniel Judge, DC by calling (248) 593-0843. If he is not available, you may make an appointment for a conference in person or by telephone within 2 working days.
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
200 Independence Avenue, SW
Room 509F HHH Building
Washington, D.C. 20201
I have read the Privacy Notice and understand my rights contained in the notice
By way of my signature, I provide Dynamic Life Chiropractic with my authorization and consent to use and disclose my protected health care information for the purposes of the treatment, payment and health care operations as described in the Privacy Notice.
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Patient’s Name (print) Date
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Patient’s Signature Date