Family Health History Template Page 6
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8Mix Family Chiropractic
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.
your answering machine or with a
In the course of your care as a patient at
person in your household. You have a
Mix Family Chiropractic, we may use or
right to confidential communications and
disclose personal and health related
to request restrictions relative to such
information about you in the following
contacts. You also have the right to be
ways:
contacted by alternative means or at
alternative locations.
*Your protected health information, including
your clinical records, may be disclosed to
another health care provider or hospital if it
We are permitted and may be required
is necessary to refer you for further
to use or disclose your health
diagnosis, assessment or treatment.
information without your authorization in
*Your health care records as well as your
these following circumstances:
billing records may be disclosed to another
party, such as an insurance carrier, an
HMO, a PPO, or your employer, if they are
*If we provide health care services to you in
or may responsible for the payment of
an emergency.
services provided to you.
*If we are required by law to provide care to
*Your name, address, phone number, and
you and we are unable to obtain your
your health care records may be used to
consent after attempting to do so.
contact you regarding appointment
*If there are substantial barriers to
reminders, information about alternatives to
communicating with you, but in our
your present care, or other health related
professional judgement we believe that you
information that may be of interest to you.
intend for us to provide care.
*If we are ordered by the courts or another
You have a right to request restrictions
appropriate agency
on our use of your protected health
You have a right to receive an
information for treatment, payment and
accounting of any such disclosures
operations purposes. Such requests are
made by this office.
not automatic and require the
agreement of this office.
Any use or disclosure of your protected
health information, other than as
Your name, address, telephone number,
outlined above, will only be made upon
e-mail address and health records may
your written authorization. If you provide
be used to contact you regarding
an authorization for release of
appointment reminders, information
information you have the right to revoke
about alternatives to your present care,
that authorization at a later date.
or other health related information that
may be of interest to you.
Information that we use or disclose
based on this privacy notice may be
If you are not home to receive an
subject to re-disclosure by the person to
appointment reminder or other related
whom we provide the information and
information, a message may be left on
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