Hipaa Notice Of Privacy Practices Form - Nebraska
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2HIPAA Notice of Privacy Practices
______________________________________________________________________________
Cornhusker Chiropractic, P.C.
Bill G. Wright D.C.
2949 N 27th St Ste 201
Lincoln NE
68521
402-466-1288
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.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to
carry out treatment, payment of health care operations (TPO) and for other purposes that are permitted or required by
law.
It also describes your rights to access and control your protected health information.
"Protected health
information" is information about you, including demographic information, that may identify you and that relates to
your past, present or future physical or mental health or condition and related health care services.
1. Uses and Disclosures of Protected Health information
Your PHI may be used and disclosed by your physician, our office staff and others outside of our office that are
involved in your care and treatment for the purpose of providing health care services to you, to pay your health care
bills, to support the operation of the physician's practice, and any other use required by law.
Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any
related services. This includes the coordination or management of your health care with a third party. For example,
we would disclose your PHI, as necessary, to a home health agency that provides care to you. For example, your
PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary
information to diagnose or treat you.
Payment: Your PHI will be used, as needed, to obtain payment for your health care services. For example,
obtaining approval for a hospital stay may require that your relevant PHI be disclosed to the health plan to obtain
approval for the hospital admission.
Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business
activities of your physicians’ practice. These activities include, but are not limited to, quality assessment activities,
employee review activities, training of medical students, licensing, and conducting or arranging for other business
activities. For example, we may disclose your PHI to medical school students that see patients at our office. In
addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate
your physician. We may also call you by name in the reception room when your physician is ready to see you. We
may use or disclose your PHI, as necessary, to contact you to remind you of your appointment.
We may use or disclose your PHI in the following situations without your authorization. These situations include: as
Required by Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or
Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral
Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers'
Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when
required by the Secretary of the Department of Health and Human Services to investigate or determine our
compliance with the requirements of Section 164.500.
Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity
to object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician's
practice has taken an action in reliance on the use or disclosure indicated in the authorization.
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