NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
PLEASE REVIEW THIS NOTICE CAREFULLY
Practice is committed to maintaining the privacy of your protected health
information ("PHI"), which includes information about your health
condition and the care and treatment you receive from the Practice.The creation of a record detailing the care
and services you receive helps this office to provide you with quality health
care.This Notice details how your PHI
may be used and disclosed to third parties.This Notice also details your rights regarding your PHI. The privacy of
PHI in patient files will be protected when the files are taken to and from the
Practice by placing the files in a box or brief case and kept within the
custody of a doctor or employee of the Practice authorized to remove the files
from the Practices office. It may be necessary to take patient files to a
facility where a patient is confined or to a patients home where the patient
is to be examined or treated.
NO CONSENT REQUIRED
Practice may use and/or disclose your PHI for the purposes of:
Treatment - In order to provide you with the health care you require, the
Practice will provide your PHI to those health care professionals, whether on
the Practice's staff or not, directly involved in your care so that they may
understand your health condition and needs.For example, a physician treating you for a condition or disease may
need to know the results of your latest physician examination by this office.
Payment - In order to get paid for services provided to you, the Practice will
provide your PHI, directly or through a billing service, to appropriate third
party payors, pursuant to their billing and payment requirements.For example, the Practice may need to provide
the Medicare program with information about health care services that you
received from the Practice so that the Practice can be properly
reimbursed.The Practice may also need
to tell your insurance plan about treatment you are going to receive so that it
can determine whether or not it will cover the treatment expense.
Health Care Operations - In order for the Practice to operate in accordance
with applicable law and insurance requirements and in order for the Practice to
continue to provide quality and efficient care, it may be necessary for the
Practice to compile, use and/or disclose your PHI.For example, the Practice may use your PHI in
order to evaluate the performance of the Practice's personnel in providing care
1. The Practice may use and/or
disclose your PHI, without a written Consent from you, in the following
De-identified Information - Information that does not identify you and, even
without your name, cannot be used to identify you.
Business Associate - To a business associate if the Practice obtains
satisfactory written assurance, in accordance with applicable law, that the
business associate will appropriately safeguard your PHI.A business associate is an entity that
assists the Practice in undertaking some essential function, such as a
collection agency or a billing company that assists the office in submitting
claims for payment to insurance companies or other payers.
Personal Representative -To a person who, under applicable law, has the
authority to represent you in making decisions related to your health care
Emergency Situations -
for the purpose of obtaining or rendering emergency treatment to you provided
that the Practice attempts to obtain your Consent as soon as possible; or
to a public or private entity authorized by law or by its charter to assist in
disaster relief efforts, for the purpose of coordinating your care with such
entities in an emergency situation.
Communication Barriers - If, due to substantial communication barriers or
inability to communicate, the Practice has been unable to obtain your Consent
and the Practice determines, in the exercise of its professional judgment, that
your Consent to receive treatment is clearly inferred from the circumstances.
Public Health Activities - Such activities include, for example, information
collected by a public health authority, as authorized by law, to prevent or
control disease and that does not identify you and, even without your name,
cannot be used to identify you.
Abuse, Neglect or Domestic Violence - To a government authority if the Practice
is required by law to make such disclosure; if the Practice is authorized by
law to make such a disclosure, it will do so if it believes that the disclosure
is necessary to prevent serious harm.
Health Oversight Activities - Such activities, which must be required by law,
involve government agencies and may include, for example, criminal
investigations, disciplinary actions, or general oversight activities relating
to the community's health care system.
Judicial and Administrative Proceeding - For example, the Practice may be
required to disclose your PHI in response to a court order or a lawfully issued
Law Enforcement Purposes - In certain instances, your PHI may have to be
disclosed to a law enforcement official.For example, your PHI may be the subject of a grand jury subpoena.Or, the Practice may disclose your PHI if the
Practice believes that your death was the result of criminal conduct.
Coroner or Medical Examiner - The Practice may disclose your PHI to a coroner
or medical examiner for the purpose of identifying you or determining your
cause of death.
Organ, Eye or Tissue Donation - If you are an organ donor, the Practice may
disclose your PHI to the entity to whom you have agreed to donate your organs.
Research - If the Practice is involved in research activities, your PHI may be
used, but such use is subject to numerous governmental requirements intended to
protect the privacy of your PHI and that does not identify you and, even without
your name, cannot be used to identify you.
Avert a Threat to Health or Safety - The Practice may disclose your PHI if it
believes that such disclosure is necessary to prevent or lessen a serious and
imminent threat to the health or safety of a person or the public and the
disclosure is to an individual who is reasonably able to prevent or lessen the
Workers' Compensation - If you are involved in a Workers' Compensation claim,
the Practice may be required to disclose your PHI to an individual or entity
that is part of the Workers' Compensation system.
Practice may, from time to time, contact you to provide appointment reminders
or information about treatment alternatives or other health-related benefits
and services that may be of interest to you.The following appointment reminders are used by the Practice: a) a
postcard mailed to you at the address provided by you; and b) telephoning your
home and leaving a message on your answering machine or with the individual
answering the phone.
REFERRAL AND THANK YOU BOARD
This Practice utilizes a letter
board located in the waiting room to recognize and thank the patients or
individuals who refer others to our Practice for care.All individuals entering the waiting room
area will be able to see the posted names.If you wish for your name not to be posted on the board, you must notify
the COMPLIANCE OFFICER in writing.
OPEN THERAPY AREA
This Practice utilizes an open
therapy area for applying and or incorporating various physiotherapeutic
modalities as may be deemed necessary by your treating doctor.This may, from time to time, require the
doctor or the person applying the particular therapy to discuss with you, while
other patients may be present in the therapy room, specific information about
the therapy or your condition which may include some of your PHI.Special care will be taken to keep this
information as discrete and specific as possible so as to protect your privacy
to the maximum possible extent.However,
it is inevitable that the discussions and or conversations in any open area may
be overheard by other patients or staff members.
E-MAILS AND NEWSLETTERS
This Practice utilizes emails as
a form of communications with its patients.You may receive various notices, announcements or newsletters via the
email address(es) that you have provided to this Practice.
Practice maintains a sign-in log for individuals seeking care and treatment in
the office.The sign-in log is located
in a position where staff can readily see who is seeking care in the office, as
well as the individual's location within the Practice's office suite.This information may be seen by, and is
accessible to, others who are seeking care or services in the Practice's
Practice may disclose to your family member, other relative, a close personal
friend, or any other person identified by you, your PHI directly relevant to
such person's involvement with your care or the payment for your care.The Practice may also use or disclose your
PHI to notify or assist in the notification (including identifying or locating)
a family member, a personal representative, or another person responsible for
your care, of your location, general condition or death.However, in both cases, the following
conditions will apply:
If you are present at or prior to the use or disclosure of your PHI, the
Practice may use or disclose your PHI if you agree, or if the Practice can
reasonably infer from the circumstances, based on the exercise of its
professional judgment, that you do not object to the use or disclosure.
If you are not present, the Practice will, in the exercise of professional
judgment, determine whether the use or disclosure is in your best interests
and, if so, disclose only the PHI that is directly relevant to the person's
involvement with your care.
and/or disclosures, other than those described above, will be made only with
your written authorization.
1. You have the right to:
Revoke any Authorization and/or Consent, in writing, at any time and to request
a revocation, you must submit a written request to the Practice's COMPLIANCE
Request restrictions on certain use and/or disclosure of your PHI as provided
by law,however, the Practice is not
obligated to agree to any requested restrictions.To request restrictions, you must submit a
written request to the Practice's COMPLIANCE OFFICER.In your written request, you must inform the
Practice of what information you want to limit, whether you want to limit the
Practice's use or disclosure, or both, and to whom you want the limits to
apply.If the Practice agrees to your
request, the Practice will comply with your request unless the information is
needed in order to provide you with emergency treatment.
Receive confidential communications or PHI by alternative means or at
alternative locations; you must make your request in writing to the Practice's
COMPLIANCE OFFICER.The Practice will
accommodate all reasonable requests.
Inspect and obtain a copy your PHI as provided by law.To inspect and copy your PHI, you are
requested to submit a written request to the Practice's COMPLIANCE
OFFICER.The Practice can charge you a
fee for the cost of copying, mailing or other supplies associated with your
Amend your PHI as provided by law.To
request an amendment, you must submit a written request to the Practice's
COMPLIANCE OFFICER.You must provide a
reason that supports your request.The
Practice may deny your request if it is not in writing, if you do not provide a
reason in support of your request, if the information to be amended was not
created by the Practice (unless the individual or entity that created the
information is no longer available), if the information is not part of your PHI
maintained by the Practice, if the information is not part of the information
you would be permitted to inspect and copy, and/or if the information is
accurate and complete.If you disagree
with the Practice's denial, you will have the right to submit a written
statement of disagreement.
Receive an accounting of disclosures of your PHI as provided by law. The
request should indicate in what form you want the list (such as a paper or
Receive a paper copy of this Privacy Notice from the Practice upon request to
the Practice's COMPLIANCE OFFICER.
Complain to the Practice or to the Office of Civil Rights, U.S. Department of
Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH
Building, Washington, D.C. 20201, 202/619-0257, email: email@example.com or to
the Georgia Attorney General if you believe your privacy rights have been
violated.To file a complaint with the
Practice, you must contact the Practice's COMPLIANCE OFFICER.All complaints must be in writing.
To obtain more information on, or have your questions about your rights
answered, you may contact the Practice's COMPLIANCE OFFICER, Hamid Sadri, D.C.,
at (404) 377-0011 or via email at DrSadri@1stChoiceOnline.com.
1. The Practice:
Is required by federal law to maintain the privacy of your PHI and to provide
you with this Privacy Notice detailing the Practice's legal duties and privacy
practices with respect to your PHI.
May be required by State law to maintain a higher level of confidentiality with
respect to certain portions of your medical information that is provided for
under federal law.
Is required to abide by the terms of this Privacy Notice.
Reserves the right to change the terms of this Privacy Notice and to make the
new Privacy Notice provisions effective for all of your PHI that it maintains.
Will distribute any revised Privacy Notice to you prior to implementation.
Will not retaliate against you for filing a complaint.
QUESTIONS AND COMPLAINTS
may obtain additional information about our privacy practices or express
concerns or complaints to the person identified below who is the COMPLIANCE
OFFICER and Contact person appointed for this practice. The COMPLIANCE OFFICER
is Hamid Sadri, D.C.
may file a complaint with the COMPLIANCE OFFICER if you believe that your
privacy rights have been violated relating to release of your protected health
information. You may, also, submit a complaint to the Department of Health and
Human Services the address of which will be provided to you by the COMPLIANCE
OFFICER. We will not retaliate against you in any way if you file a complaint.
This Notice is in effect as of April 1, 2003.