NOTICE OF PRIVACY PRACTICES This notice describes how your protected health information (PHI) may be used, disclosed, and how you can access this information. We must abide by the terms of this notice while it is effect. This notice is in effect as of April 14, 2003. Please review it carefully. The Privacy of your health information is important to us, and it is our legal duty to protect it. USES AND DISCLOSURES OF YOUR PHI We use and disclose health information about you for treatment, payment, and health care operation. Treatment: We may use or disclose your PHI to another healthcare provider providing care to you for the use of diagnosis and treatment. Payment: We may use and disclose your PHI in order to process claims and seek reimbursement for your health expenses covered by an insurer or plan. Health Operations: We may use and disclose your PHI in our health operations including quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities. OTHER PERMITTED OR REQUIRED DISCLOSURES OF YOUR PHI As required by Law. We may disclose your PHI when required by law. Public Health Activities. We may disclose your PHI to public health agencies for reasons such as preventing or controlling disease, mental injury or disability, and/or posting marketing information to enable product recalls, repairs, or replacements. Military and Veterans. If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may disclose PHI about foreign military personnel to the appropriate agencies. Correctional Institution. If you are or become an inmate of a correctional institution, we may release your PHI to the institution or its agents when necessary to protect your personal or public health. Victims of Abuse, Neglect or Domestic Violence. We may disclose your PHI to government agencies if we reasonably believe you are a victim of abuse, neglect or domestic violence. Health Oversight Activities. We may disclose your PHI to government oversight agencies as authorized by law, including audits, investigations, and inspections, as necessary for our licensure and for the government to monitor the health care system and compliance with laws and regulations. Judicial and Administrative proceedings. We may disclose your PHI in response to a court, administrative order, a subpoena, discovery request, or other lawful process. Coroners, Medical Examiners, Funeral Directors, Organ Donation. We may release your PHI to coroners, medical examiners, funeral directors or in connection with organ or tissue donation. Research. We may disclose PHI about you for research purposes when the research is approved by an institutional review board, provided certain measures have been taken to protect your privacy. To Avert a Serious Threat to Health or Safety. We may disclose your PHI, with some limitations, when necessary to prevent a serious threat to your, the publics, or another persons health and safety. Special Government Functions. We may disclose your PHI as required by military authorities or to authorized federal officials for national security or intelligence activities. OTHER USES AND DISCLOSURES OF PHI WITH AN AUTHORIZATION Other uses or disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke an authorization at any time in writing, except to the extent we have already taken action on the information disclosed or if we are permitted by law to use the information. YOUR RIGHTS REGARDING YOUR PHI You have certain rights regarding your PHI that we maintain for you. You have the right to: Access Your PHI. You have a right to review or obtain copies of your PHI records, with some limited exceptions. These records usually include case history, treatment, management, claims and billing information. To inspect or copy your PHI, you must request it in writing. We may charge you an administrative fee for the costs of copying, mailing and supplies necessary to fulfill your request. If you are denied access due to certain limited circumstances, you may request that the denial be reviewed. Amend Your PHI. If you feel that the PHI maintained by us is incorrect or incomplete, you may request that we amend the information. Your request must be made in writing and must include the reason you are seeking a change. We may deny your request if, for example, you ask us to amend information that was not created by us, or you ask to amend a record that is already accurate and complete. If we deny your request to amend, we will notify you in writing. You then have and right to submit to us a written statement of disagreement with our decision and we have the right to rebut your statement. An Accounting of Disclosures by Us. You have the right to request an accounting of disclosures we have made about your PHI. The list will not include our disclosures related to your treatment, billing or receipt of payment, health care operations, for notification purposes, disclosures made to you, or with your authorization. Your request for an accounting of disclosures must be made in writing and must state the time period for which you want an accounting. This time period may not be longer than six years and may not include dates before April 14, 2003. The accounting that you request within a 12-month period will be free. We may charge for additional accountings within the same period of time. You will be informed of the cost in advance and you may choose to withdraw or modify your request at that time. Request Restrictions on the Use and Disclosure of Your PHI. You have the right to request that we restrict or limit how we use or disclose your PHI for treatment, payment or health care operations. Your request for a restriction must be made in writing. Your request must tell us: 1) what information you want to limit; 2) whether you want to limit how we use or disclose you information, or both; and 3) to whom you want the restrictions to apply. We may agree to your request. If we do agree, we will comply with your request unless the information is needed for an emergency or required law. Receive Confidential Communications. You have the right to request that we use a certain method to communicate with you about your PHI or that we send any information to a certain location in the communication could endanger you. Your request to receive confidential communications must be made in writing and must clearly state that all or part of the communication from us could endanger you. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests. Receive a Paper Copy of this Notice. You have a right at any time to request a paper copy of this notice, even if you had previously agreed to receive an electronic copy. Contact Information for Exercising Your Rights. You may exercise any of the rights described above by contacting Sammamish Chiropractic. See the end of this notice for contact information. HEALTH INFORMATION SECURITY We require our employees to follow Sammamish Chiropractic's security practices that limit access to patient’s PHI only to those employees who need it to perform their job responsibilities. In addition, Sammamish Chiropractic maintains physical, administrative and technical security measures to safeguard your PHI. CHANGES TO THIS NOTICE We reserve the right to change the terms of this notice at any time, effective for PHI that we already have about you as well as any information that we receive in the future. We will provide you with a copy of any new notice whenever we make a material change to the privacy practices described in this notice. We will also post a copy of our current notice on the Sammamish Chiropractic website, Samchiro.com. COMPLAINTS If you believe that your privacy rights have been violated, you may file a complaint with us and/or the Secretary of the Department of Health and Human Services. All complaints regarding Sammamish Chiropractic must be in writing and sent to the address listed at the end of this notice. We support your right to protect the privacy of you PHI and we will not retaliate against you for filing a complaint. Alastair Harper, DC Sammamish Chiropractic 660 NW Gilman Blvd., Suite C4 Issaquah, WA 98027 Return to: Forms | Sammamish Chiropractic Homepage