NOTICE OF PRIVACY PRACTICES
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1 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW IT CAREFULLY. Le M. Kenney, DC, FACO respects yur privacy. We understand that yur persnal health infrmatin is very sensitive. We will nt disclse yur infrmatin t thers unless yu tell us t d s, r unless the law authrizes r requires us t d s. The law prtects the privacy f the health infrmatin we create and btain in prviding ur care and services t yu. Fr example, yur prtected health infrmatin includes yur symptms, test results, diagnses, treatment, health infrmatin frm ther prviders, and billing and payment infrmatin relating t these services. Federal and state law allws us t use and disclse yur prtected health infrmatin fr purpses f treatment and health care peratins. State law requires us t get yur authrizatin t disclse this infrmatin fr payment purpses. Examples f Use and Disclsures f Prtected Health Infrmatin fr Treatment, Payment, and Health Operatins Fr treatment: Infrmatin btained by a nurse, physician, r ther member f ur health care team will be recrded in yur health recrd and used t help decide what care may be right fr yu. We may als prvide infrmatin t thers prviding yu care. This will help them stay infrmed abut yur care. Fr payment: We request payment frm yur health insurance plan. Health plans need infrmatin frm us abut yur health care. Infrmatin prvided t health plans may include yur diagnses; prcedures perfrmed, r recmmended care. Fr health care peratins: We use yur health recrds t assess quality and imprve services. We may use and disclse health recrds t review the qualificatins and perfrmance f ur health care prviders and t train ur staff. We may cntact yu t remind yu abut appintments and give yu infrmatin abut treatment alternatives r ther health-related benefits and services. We may cntact yu t raise funds. We may cntact the individuals wh referred yu t thank them fr the referral.
2 We may use and disclse yur infrmatin t cnduct r arrange fr services, including: health quality review by yur health plan; accunting, legal, risk management, and insurance services; audit functins, including fraud and abuse detectin and cmpliance prgrams. Yur Health Infrmatin Rights The health and billing recrds we create and stre are the prperty f the practice/health care facility. The prtected health infrmatin in it, hwever, generally belngs t yu. Yu have a right t: Receive, read, and ask questins abut this Ntice; Ask us t restrict certain uses and disclsures. Yu must deliver this request in writing t us. We are nt required t grant the request. But we will cmply with any request granted; Request and receive frm us a paper cpy f the mst current Ntice f Privacy Practices fr Prtected Health Infrmatin ( Ntice ); Request that yu be allwed t see and get a cpy f yur prtected health infrmatin. Yu may make this request in writing. We have a frm available fr this type f request. Have us review a denial f access t yur health infrmatin except in certain circumstances; Ask us t change yur health infrmatin. Yu may give us this request in writing. Yu may write a statement f disagreement if yur request is denied. It will be stred in yur health recrd, and included with any release f yur recrds. When yu request, we will give yu a list f disclsures f yur health infrmatin. The list will nt include disclsures t third party payrs. Yu may receive this infrmatin withut charge nce every 12 mnths. We will ntify yu f the cst invlved if yu request this infrmatin mre than nce in 12 mnths. Ask that yur health infrmatin be given t yu by anther means r at anther lcatin. Please sign, date, and give us yur request in writing. Cancel prir authrizatins t use r disclse health infrmatin by giving us a written revcatin. Yur revcatin des nt affect infrmatin that has already been released. It als des nt affect any actin taken befre we have it. Smetimes, yu cannt cancel an authrizatin if its purpse was t btain insurance.
3 Fr help with these rights during nrmal business hurs, please cntact: Our Respnsibilities We are required t: Keep yur prtected health infrmatin private; Give yu this Ntice; Fllw the terms f this Ntice. We have the right t change ur practices regarding the prtected health infrmatin we maintain. If we make changes, we will update this Ntice. Yu may receive the mst recent cpy f this Ntice by calling and asking fr it r by visiting ur ffice. T Ask fr Help r Cmplain If yu have questins, want mre infrmatin, r want t reprt a prblem abut the handling f yur prtected health infrmatin, yu may cntact: Le M. Kenney, DC, FACO 3316 White Muntain Highway Nrth Cnway NH If yu believe yur privacy rights have been vilated, yu may discuss yur cncerns with any staff member. Yu may als deliver a written cmplaint t [name r title f persn] at ur practice/health care facility. Yu may als file a cmplaint with the U.S. Secretary f Health and Human Services. We respect yur right t file a cmplaint with us r with the U.S. Secretary f Health and Human Services. If yu cmplain, we will nt retaliate against yu. Other Disclsures and Uses f Prtected Health Infrmatin Ntificatin f Family and Others Unless yu bject, we may release health infrmatin abut yu t a friend r family member wh is invlved in yur health care. We may als give infrmatin t smene wh helps pay fr yur care. We may tell yur family r friends yur cnditin and that yu are in a hspital. In additin, we may disclse health infrmatin abut yu t assist in disaster relief effrts. [Hspitals] Infrmatin may be prvided t peple wh ask fr yu by name. We may use and disclse the fllwing infrmatin in a hspital directry: yur name, lcatin, general cnditin, and Religin (nly t clergy). Yu have the right t bject t this use r disclsure f yur infrmatin. If yu bject, we will nt use r disclse it.
4 We may use and disclse yur prtected health infrmatin withut yur authrizatin as fllws: With health researchers if the research has been apprved and has plicies t prtect the privacy f yur health infrmatin. We may als share infrmatin with health researchers preparing t cnduct a research prject. T Funeral Directrs/Crners cnsistent with applicable law t allw them t carry ut their duties. T the Fd and Drug Administratin (FDA) relating t prblems with fd, supplements, and prducts. T cmply with wrkers cmpensatin laws--if yu make a wrkers cmpensatin claim. Fr Public Health and Safety purpses as allwed r required by law: t prevent r reduce a serius, immediate threat t the health r safety f a persn r the public. t public health r legal authrities t prtect public health and safety t prevent r cntrl disease, injury, r disability t reprt vital statistics such as births r deaths. T reprt suspected Abuse r Neglect t public authrities. T Crrectinal Institutins if yu are in jail r prisn, as necessary fr yur health and the health and safety f thers. Fr Law Enfrcement purpses such as when we receive a subpena, curt rder, r ther legal prcess, r yu are the victim f a crime. Fr Health and Safety versight activities. Fr example, we may share health infrmatin with the Department f Health. Fr Disaster Relief Purpses. Fr example, we may share health infrmatin with disaster relief agencies t assist in ntificatin f yur cnditin t family r thers. Fr Wrk-Related Cnditins That Culd Affect Emplyee Health. Fr example, an emplyer may ask us t assess health risks n a jb site. T the Military Authrities f U.S. and Freign Military Persnnel. Fr example, the law may require us t prvide infrmatin necessary t a military missin. In the Curse f Judicial/Administrative Prceedings at yur request, r as directed by a subpena r curt rder. Fr Specialized Gvernment Functins. Fr example, we may share infrmatin fr natinal security purpses.
5 Other Uses and Disclsures f Prtected Health Infrmatin Uses and disclsures nt in this Ntice will be made nly as allwed r required by law r with yur written authrizatin. Web Site We have a Web site that prvides infrmatin abut us. Fr yur benefit, this Ntice is n the Web site at this address: Effective Date: April 1, Ntice f Privacy Practices -- Acknwledgement We keep a recrd f the health care services we prvide yu. Yu may ask t see and cpy that recrd. Yu may als ask t crrect that recrd. We will nt disclse yur recrd t thers unless yu direct us t d s r unless the law authrizes r cmpels us t d s. Yu may see yur recrd r get mre infrmatin abut it by cntacting Danette MacArthur r Dr. Le Kenney. Our Ntice f Privacy Practices describes in mre detail hw yur health infrmatin may be used and disclsed, and hw yu can access yur infrmatin. By my signature belw I acknwledge receipt f the Ntice f Privacy Practices. Signature f patient r authrized representative Date Printed name if signed n behalf f patient / Relatinship (parent, legal guardian, persnal representative, etc.) (Ntatin, if any, by staff) This frm will be retained in yur health recrd.
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