Burdette Family Chiropractic and Wellness Center, Inc.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Burdette Family Chiropractic and Wellness Center, 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 Practice may use and/or disclose your PHI provided that it first obtains a valid Consent signed by
you. The Consent will allow the Practice to use and/or disclose your PHI for the purposes of:
(a) 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 lower back pain may need to know the results of your latest physician examination by this
(b) 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.
(c) 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 to evaluate the performance of the Practice's personnel in providing care
NO CONSENT REQUIRED
• The Practice may use and/or disclose your PHI, without a written Consent from you, in the following
(a) De-identified Information - Information that does not identify you and, even without your name,
cannot be used to identify you.
(b) 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 billing company that assists the office in submitting claims for payment to insurance
companies or other payers.
(c) Personal Representative - To a person who, under applicable law, has the authority to represent you
in making decisions related to your health care.
(d) Emergency Situations -
(i) 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
(ii) 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.
(e) 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
(f) Public Health Activities - Such activities include, for example, information collected by a public health
authority, as authorized by law, to prevent or control disease.
(g) 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.
(h) 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.
(i) 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 subpoena.
(j) 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
(k) 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.
(l) 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.
(m) 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.
(n) 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 threat.
(o) Specialized Government Functions - This refers to disclosures of PHI that relate primarily to military
and veteran activity.
(p) 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
(q) National Security and Intelligence Activities — The Practice may diSclose your PHI in order to
provide authorized governmental officials with necessary intelligence information for national security
activities and purposes authorized by law.
(r) Military and Veterans - If you are a member of the armed forces, the Practice may disclose your PHI
as required by the military command authorities.
• The 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 or by e-mail.
• The Practice maintains a directory of and sign-in log for individuals seeking care and treatment in the
office. Directory and sign-in log are 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 offices.
• The 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
(a) 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.
(b) 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.
• Uses and/or disclosures, other than those described above, will be made only with your written Authorization.
• You have the right to:
(a) Revoke any Authorization and/or Consent, in writing, at any time. To request a revocation, you must
submit a written request to the Practice's Privacy Officer.
(b) 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 Privacy 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.
(c) Receive confidential communications or PHI by alternative means or at alternative locations. You
must make your request in writing to the Practice's Privacy Officer. The Practice will accommodate
all reasonable requests.
(d) Inspect and copy your PHI as provided by law. To inspect and copy your PHI, you must submit a
written request to the Practice's Privacy Officer. The Practice can charge you a fee for the cost of
copying, mailing or other supplies associated with your request. In certain situations that are defined
by law, the Practice may deny your request, but you will have the right to have the denial reviewed
as set forth more fully in the written denial notice.
(e) Amend your PHI as provided by law. To request an amendment, you must submit a written request
to the Practice's Privacy 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.
(f) Receive an accounting of disclosures of your PHI as provided by law. To request an accounting, you
must submit a written request to the Practice's Privacy Officer. The request must state a time period
which may not be longer than six (6) years and may not include dates before April 14, 2003. The
request should indicate in what form you want the list (such as a paper or electronic Copy). The first
list you request within a twelve (12) month period will be free, but the Practice may charge you for
the cost of providing additional lists. The Practice will notify you of the costs involved and you can
decide to withdraw or modify your request before any costs are incurred.
(g) Receive a paper copy of this Privacy Notice upon request to the Practice's Privacy Officer.
(h) Complain to the Practice or to the Secretary of HHS if you believe your privacy rights have been
violated. To file a complaint with the PractiCe, you must contact the Practice's Privacy Officer. All
complaints must be in writing.
(i) To obtain more information on, or have your questions about your rights answered, you may contact
the Practice's Privacy Officer, April Campbell, at (304) 363-4006.
• The Practice:
(a) 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.
(b) Is 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. In particular, the Practice is required
to comply with the following State statutes:
(c) is required to abide by the terms of this Privacy Notice.
(d) 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.
(e) Will distribute any revised Privacy Notice to you prior to implementation.
(f) Will not retaliate against you for filing a complaint.
• This Notice is in effect as of 01/24/05.
Burdette Family Chiropractic and Wellness Center
FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
TO CARRY OUT TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS