NOTICE OF PRIVACY PRACTICES | PATIENT'S BILL OF RIGHTS

If you have any questions about this Notice please contact our Privacy Officer who is Jeremy Rosner, D.C. 

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations 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.  

We are required to abide by the terms of this Notice of Privacy Practices.  We may change the terms of our notice, at any time.  The new notice will be effective for all protected health information that we maintain at that time.  Upon your request, we will provide you with any revised Notice of Privacy Practices.  You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.  

1.USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION  Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you.  Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician’s practice.  

Following are examples of the types of uses and disclosures of your protected health information that your physician’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.  

Treatment:  We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.  This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you.  We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information 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.  In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician. We provide treatment in a relaxed, "open treatment area", if at any time you wish to discuss your specific case or would like to have treatment in a private room, please ask. If you wish to always have treatment in a private room, please indicate this as well so we can have you sign the necessary paperwork. 

Payment:  Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider.  This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.  For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.   

Health Care Operations:  We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice.  These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities.  

We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our practice.  Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.  

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.  You may contact our Privacy Officer to request that these materials not be sent to you.  

We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office.  If you do not want to receive these materials, please contact our Privacy Officer and request that these fundraising materials not be sent to you.  

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object   

We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object.  These situations include:  

Required By Law:  We may use or disclose your protected health information to the extent that the use or disclosure is required by law.  The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.  You will be notified, if required by law, of any such uses or disclosures.

Public Health:  We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.  For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.  

Communicable Diseases:  We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.  

Health Oversight:  We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.  Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.   

Abuse or Neglect:  We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect.  In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information.  In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.  

Food and Drug Administration:  We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.  

Legal Proceedings:  We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.   

Law Enforcement:  We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes.  These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice’s premises) and it is likely that a crime has occurred.   

Coroners, Funeral Directors, and Organ Donation:  We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law.  We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties.  We may disclose such information in reasonable anticipation of death.  Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.  

Research:  We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.  

Criminal Activity:  Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.  We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.   

Military Activity and National Security:  When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services.  We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.   

Workers’ Compensation:  We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs.  

Inmates:  We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.  

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization  

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below.  You may revoke this authorization in writing at any time.  If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization.  

Please understand that we are unable to take back any disclosures already made with your authorization.  Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object  

We may use and disclose your protected health information in the following instances.  You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information.  If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgement, determine whether the disclosure is in your best interest. 

Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation.  All of this information, except religious affiliation, will be disclosed to people that ask for you by name.  Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi.  

Others Involved in Your Health Care or Payment for your Care:  Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care.  If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.  We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.  Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.  

2. YOUR RIGHTS 

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.  

You have the right to inspect and copy your protected health information.  This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information.  You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you.  As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records.   

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable.  In some circumstances, you may have a right to have this decision reviewed.  Please contact our Privacy Officer if you have questions about access to your medical record.   

You have the right to request a restriction of your protected health information.  This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations.  You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.  Your request must state the specific restriction requested and to whom you want the restriction to apply.   

Your physician is not required to agree to a restriction that you may request.  If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment.  With this in mind, please discuss any restriction you wish to request with your physician.  You may request a restriction by providing a written request.  

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.  We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.  

You may have the right to have your physician amend your protected health information.   This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information.  In certain cases, we may deny your request for an amendment.  If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.  Please contact our Privacy Officer if you have questions about amending your medical record.   

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.  This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices.  It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure.  You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations.   

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.  

3. COMPLAINTS  

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.  You may file a complaint with us by notifying our Privacy Officer of your complaint.  

We will not retaliate against you for filing a complaint.  You may contact our Privacy Officer, Jeremy Rosner, D.C.at (810) 632-5252 via email at Rosner@wellnes4lifechiro.com for further information about the complaint process.  

This notice was published and becomes effective on 4/1/2010 and was updated on  5/20/21. 

 A patient should expect and receive from doctors of chiropractic entrusted with the responsibility of delivering chiropractic care, consideration of their basic rights as human beings to independence of expression, decisions and actions; and concern and respect for their personal dignity at all times.

The following patient’s rights are an integral part of Wellness 4 Life Chiropractic's Code of Professional Ethics and the patient should be advised of these rights.

1. The patient has the right to impartial access to chiropractic care without regard to race; sex; cultural, national or ethnic origins; economic, educational, religious or political affiliation; and without having to disclose the source of payment for his/her care.

2. The patient has the right to be interviewed and examined in surroundings that permit reasonable visual and auditory privacy. Individuals not directly involved in his/her care will not be present without the patient’s permission. The patient has the right to be advised of the presence of any individual during consultation and/or care and the reason for their presence.

3. The patient has the right to have a person of his/her choosing present during physical examinations and the right not to remain disrobed any longer than is required for accomplishing the examination for which the patient was asked to disrobe.

4. The patient should know the identity and professional status of individual(s) providing service to him/her and to know who has the primary responsibility for coordinating his/her care. This includes the right to know the professional relationships among individuals who are caring for him/her as well as the relationship to any other health care.

5. The patient has the right to expect information from the doctor of chiropractic coordinating his/her care concerning the diagnosis/analysis, prognosis and the planned course of care in terms that the patient is able to understand. When it is not clinically advisable to give such information to the patient, the information should be made available to a legally authorized representative of the patient.

6. The patient has the right to actively participate in any and all decisions regarding his/her care. To the extent permissible by applicable law, this will include the right to refuse care even after being informed of possible adverse consequences of his/her decision. When a patient or his/he legally authorized representative refused procedures which prevent the doctor of chiropractic from providing care in accordance with professional standards, the relationship with the patien may be terminated upon reasonable notice.

7. The patient has the right not to be subjected to any procedure(s) without voluntary consent or the consent of his/her legally authorized representative. When alternatives to chiropractic care exist, the patient can be expected to be informed of these alternatives.

8. The patient has the right to expect confidential care of all communications and records pertaining to his/her care. The patient also has the right to have his/her health care record read only by individuals directly involved in his/her care or in monitoring of its quality and by othe individuals only on the patient’s written authorization or that of his/her legally authorized representative. Written permission shall be obtained before health care records are made available to anyone not directly concerned with the patient’s care.

9. The patient has the right to leave or voluntarily be discharged from chiropractic care even against the best advice of the attending doctor of chiropractic.

10. A patient can expect reasonable continuity of care. He/she shall be informed in advance of the time(s) and location(s) of appointments.

11. The patient has the right, upon request, to receive an itemized, detailed and thorough explanation of total charges billed for services rendered, regardless of the source of payment. The patient has the right to timely notice prior to termination of his/her eligibility for reimbursement by any third-party payer for the cost of his/her care.

12. The patient shall be advised of his/her rights and shall be instructed as to the rules and policies which apply to his/her conduct as a patient in the office setting.

13. The patient shall have all his/her rights also applied to the person or persons who may assume the legal responsibility to make decisions on the patient’s behalf regarding the care of the patient should the patient be a legal minor or otherwise incapacitated.

14. The patient has the right to expect reasonable safety insofar as the health care environment is concerned.

15. The patient, at his/her own request and expense, has the right to consult with another health care practitioner.

PATIENT’S RESPONSIBILITIES

1. Provision of Information

A patient has the responsibility to provide, to the best of his/her ability and knowledge, accurate and complete information about present complaints, past illnesses, accidents, hospitalizations, medications, and other matters relating to his/her health. It is the patient’s responsibility to report any new episode of trauma or any unexpected changes in his/her health condition to the practitioner. The patient is responsible for making it be known if he/she does not fully comprehend the practitioner’s contemplated course of care.

2. Compliance with Instructions

A patient is responsible for following the care plan recommended by the practitioner primarily responsible for his/her care. The patient is responsible for keeping appointments and, when unable to do so, for notifying the practitioner or his/her office.

3. Refusal of Care

The patient is responsible for the consequences if he/she refuses care or does not follow the practitioner’s instructions

4. Charges

The patient is responsible for assuring that the financial obligations of his/her health care are fulfilled as promptly as possible.

5. Clinic Rules and Regulations

The patient is responsible for following office rules and regulations affecting patient care and conduct.

6. Respect and Consideration

The patient is responsible for being considerate of the rights of other patients. He/she is also responsible for being respectful of the property of other persons and of the offices and environment in which care is rendered.

REMUNERATION

The health and welfare of the patient should always be paramount and expectation of remuneration or lack thereof shall not in any way affect the quality of service rendered to the patient.

Wellness 4 Life Chiropractic is entitled to receive proper and reasonable compensation for professional services rendered compared to the fees commonly assessed in the community by other members of the profession based on usual and customary practices, experience,

time, reputation, the nature of the patient’s condition and the patient’s ability to pay.

Wellness 4 Life Chiropractic will be prepared to discuss fees with individual patients and  should initiate discussion when fees are expected to exceed usual and customary charges.

Wellness 4 Life Chiropractic should support proper activities designed to access necessary chiropractic care on behalf of individuals who are unable to pay reasonable chiropractic fees or who are otherwise legally destitute.