HIPAA Privacy Practice for Blue Skies Chiropractic Health Center, P.C.
PLEASE REVIEW THIS NOTICE CAREFULLY. IT DESCRIBES HOW YOUR MEDICAL INFORMATION MAY
BE USED AND DISCLOSED AND HOW YOU MAY GAIN ACCESS TO THAT INFORMATION.
This Practice is committed to maintaining the privacy of your protected health information (“PHI”), which
includes information about your medical condition and the care and treatment you receive from the Practice
and other health care providers. This Notice details how your PHI may be used and disclosed to third parties
for purposes of your care, payment for your care, health care operations of the Practice, and for other
purposes permitted or required by law. This Notice also details your rights regarding your PHI.
USE OR DISCLOSURE OF PHI
The Practice may use and/or disclose your PHI for purposes related to your care, payment for your care, and
health care operations of the Practice. The following are examples of the types of uses and/or disclosures of
your PHI that may occur. These examples are not meant to include all possible types of use and/or disclosure.
Care – In order to provide care to you, the Practice will provide your PHI to those health care professionals
directly involved in your care so they may understand your medical condition and needs and provide advice
or treatment. For example, your physician may need to know how your condition is responding to the
treatment provided by the Practice.
Payment – In order to get paid for some or all of the health care provided by the Practice, the Practice may
provide your PHI, directly or through a billing service, to appropriate third party payers, pursuant to their
billing and payment requirements. For example, the Practice may need to provide your health insurance
carrier with information about health care services you received from the Practice so the Practice may be
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 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 in order to evaluate the performance of the Practice’s personnel in providing care to you.
Note: Genetic information is protected by law and is not considered part of Health Care Operations.
Fundraising – To the extent that the Practice engages in fundraising activities (i.e. appeals for money, help,
or event sponsorships), certain types of PHI may be disclosed for these purposes, unless you specifically
‘opt out’ of receiving notification. To ‘opt out’, call or email the Practice to be excluded from fundraising
AUTHORIZATION NOT REQUIRED
The Practice may use and/or disclose your PHI, without a written Authorization from you, in the following
1. De-identified Information – Your PHI is altered so that it does not identify you and, even without your name,
cannot be used to identify you.
1. Business Associate – To a business associate, who is someone the Practice contracts with to provide a
service necessary for your treatment, payment for your treatment and/or health care operations (e.g., billing
service or transcription service). The Practice will obtain satisfactory written assurance, in accordance with
applicable law, that the business associate and their subcontractors will appropriately safeguard your PHI.
2. Personal Representative – To a person who, under applicable law, has the authority to represent you in
making decisions related to your health care.
3. Public Health Activities – Such activities include, for example, information collected by a public health
authority, as authorized by law, to prevent or control disease, injury or disability. This includes reports of
child abuse or neglect.
4. Federal Drug Administration – If required by the Food and Drug Administration to report adverse events,
product defects, problems, biological product deviations, or to track products, enable product recalls,
repairs or replacements, or to conduct post marketing surveillance.
5. 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 the disclosure is necessary to prevent serious harm or if the Practice believes you have been the
victim of abuse, neglect or domestic violence. Any such disclosure will be made in accordance with the
requirements of law, which may also involve notice to you of the disclosure.
6. Health Oversight Activities – Such activities, which must be required by law, involve government agencies
involved in oversight activities that relate to the health care system, government benefit programs,
government regulatory programs and civil rights law. Those activities include, for example, criminal
investigations, audits, disciplinary actions, or general oversight activities relating to the commmunity’s
health care system.
7. Family and Friends - Unless expressly prohibited by you, the Practice may disclose PHI to a member of
your family, a relative, a close friend or any other person you identify, as it directly relates to that person’s
involvement in your health care. If you do not express an objection or are unable to 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.
8. 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.
9. Law Enforcement Purposes – In certain instances, your PHI may have to be disclosed to a law
enforcement official for law enforcement purposes. Law enforcement purposes include: (1) complying with
a legal process (i.e., subpoena) or as required by law; (2) information for identification and location
purposes (e.g., suspect or missing person); (3) information regarding a person who is or is suspected to be
a crime victim; (4) in situations where the death of an individual may have resulted from criminal conduct;
(5) in the event of a crime occurring on the premises of the Practice; and (6) a medical emergency (not on
the Practice’s premises) has occurred, and it appears that a crime has occurred.
11. 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, or to a funeral director as permitted by
law and as necessary to carry out its duties.
12. 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.
13. 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 such as approval of
the research by an institutional review board, the de-identification of your PHI before it is used, and the
requirement that protocols must be followed. Individuals have the option to ‘opt out’ of certain types of
14. 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.
15. Specialized Government Functions – When the appropriate conditions apply, the Practice may use PHI 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 Veteran Affairs of
eligibility for benefits; or (3) to a foreign military authority if you are a member of that foreign military
service. The Practice may also disclose your PHI to authorized federal officials for conducting national
security and intelligence activities including the provision of protective services to the President or others
16. Inmates – The Practice may disclose your PHI to a correctional institution or a law enforcement official if
you are an inmate of that correctional facility and your PHI is necessary to provide care and treatment to
you or is necessary for the health and safety of other individuals or inmates.
17. 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 system.
18. Disaster Relief Efforts – The Practice may use or disclose your PHI to a public or private entity authorized
to assist in disaster relief efforts.
19. Marketing - Face to face communication directly with the patient, treatment and coordination of care
activities, refill reminders or communications about drugs that have already been prescribed, or
promotional gifts of nominal value do not require authorization as long as the Practice receives no financial
remuneration for making the communication. All other situations require separate authorization.
20. Required by Law – If otherwise required by law, but such use or disclosure will be made in compliance with
the law and limited to the requirements of the law.
Uses and/or disclosures, other than those described above, will be made only with your written Authorization.
These authorizations may be revoked at any time, however, we cannot take back disclosures already made
with your permission.
We also will NOT use or disclose your PHI for the following purposes, where applicable, without your express
Marketing - This does not including marketing communications described in item #19. The Practice will
obtain prior authorization before disclosing PHI in connection with marketing activities in which financial
remuneration is received.
Sales - The Practice may receive payment for sharing your information in specific situations (i.e. public
health purposes or specific research projects - see #12 above).
Specially protected information - Certain types of information such as psychotherapy notes, HIV status,
substance abuse, mental health, and genetic testing information require their separate written authorization for
the purposes of treatment, payment or healthcare operations.
The Practice may, from time to time, contact you to provide appointment reminders. The reminder may be in
the form of a letter or postcard. The Practice will try to minimize the amount of information contained in the
reminder. The Practice may also contact you by phone and, if you are not available, the Practice will leave a
message for you.
The Practice may, from time to time, contact you about treatment alternatives it offers, or other health benefits
or services that may be of interest to you.
You have the right to:
Revoke any Authorization, in writing, at any time. To request a revocation, you must submit a written
request to the Practice’s Privacy Officer. Marketing revocations may be submitted to the Practice via
telephone or email.
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.
Restrict disclosures to your health plan when you have paid out-of-pocket in full for health care items or
services provided by the Practice.
Receive confidential communications of 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
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. 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. The Practice may charge you a fee (to
cover costs incurred by the Practice to reproduce records) for the cost of copyiing, mailing or other supplies
associated with your request.
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 originating 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 have the right to
submit a written statement of disagreement.
Receive an accounting of non-routine 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 years and may not include the 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 12 month period will be free, but the Practice may charge you for the cost of providing
additional lists in that same 12 month period. The Practice will notify you of the costs involved and you can
decide to withdraw or modify your request before any costs are incurred.
Receive a paper copy of this Notice of Privacy Practices from the Practice upon request.
To file a complaint with the Practice, please contact the Practice’s Privacy Officer. All complaints must be in
writing. If your complaint is not satisfactorily resolved, you may file a complaint with the Secretary of Health
and Human Services, Office for Civil Rights. Our Privacy Officer will furnish you with the address upon
To obtain more information, or have your questions about your rights answered, please contact the
Practice’s Privacy Officer (our office manager Katelyn).
The health care office:
Is required by law to maintain the privacy of your PHI and to provide you with this Notice of Privacy
Practices upon request.
Is required to abide by the terms of this Notice of Privacy Practices.
Reserves the right to change the terms of this Notice of Privacy Practices and to make the new Notice of
Privacy Practices provisions effective for all of your PHI that it maintains.
Will not retaliate against you for making a complaint.
Must make a good faith effort to obtain from you an Acknowledgment of receipt of this Notice.
Will post this Notice of Privacy Practices in its lobby and on the Practice’s web site, if the Practice
maintains a Web site.
Will inform you in a timely manner, if there is a case of a breach of unsecured health information.
Form Copyright © 2013 by InstaCode Institute.