NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

In conducting our business, we will create records regarding you and the treatment and services we provide to you. Our goal is to take appropriate steps to attempt to safeguard any medical or other personal information that is provided to us. The Privacy Rule under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") requires us to (i) maintain the privacy of medical information provided to us; (ii) provide notice of our legal duties and privacy practices; and (iii) abide by the terms of our Notice of Privacy Practices currently in effect.

We may use and disclose your individually identifiable health information (IIHI) about you in the following ways. The following categories describe the different ways in which we may use and disclose your individually identifiable health information, but not every use or disclosure in a category is listed.

For Treatment We may use your health information to provide you with medical treatment or services. For example, we may use your medical history such as the absence or presence of a condition to assess its relationship to your current complaints. Or, we might disclose your IIHI to a Physician or facility we are referring you to. We may provide your Primary Care Physician with copies of various reports that should assist him or her in treating you.

For Payment WE may use and disclose health information about you to bill for our services and to collect payment from you or your insurance company. For example, we may need to give a payer information about your current medical condition so that it will pay us for the services we have furnished you. We may also need to inform your payer of the treatment you are going to receive in order to obtain prior approval or to determine whether the service is covered.

For Health Care Operations We may use and disclose information about you for the general operation of our business. For example, we sometimes arrange for auditors or other consultants to review our practices, evaluate our operations, and tell us how to improve our services. Or, for example, we may use and disclose your health information to review the quality of services provided to you.

Required Disclosures We may disclose health information about you when we are required to do so by federal, state or local law. We are required to disclose health information about you to the Secretary of Health and Human Service, upon request, to determine our compliance with HIPAA.

As required by law, we may disclose your IIHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability. Health information about you also may be disclosed when necessary to prevent a serious threat to the health and safety of yourself or others.

We may disclose IIHI for law enforcement purposes as required by law or in response to a valid warrant, summons, court order, subpoena or similar legal process.

We may disclose your IIHI to a health oversight agency for activities authorized by law or necessary for the government to monitor government programs, compliance with civil rights law and the health care system in general.

We may use and disclose your IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

We may release your IIHI to workers' compensation or similar programs, which provide benefits for work-related injuries or illnesses without regard to fault.

If you are a member of the Armed Forces, we may release health information about you for activities deemed necessary by military command authorities.

If you are an inmate, we may release protected health information about you to a correctional institution where you are incarcerated or to law enforcement officials in certain situations where the information is necessary for your treatment, health or safety, or the health or safety of others.

We may disclose protected health information for national security and intelligence activities and for the provision of protective services to the President of the United States and other officials or foreign heads of state.

We sometimes work with outside individuals and businesses that help us operate our business. We may disclose your health information to these business associates so that they can perform the tasks that we hire them to do. Our business associates must promise that they will appropriately safeguard and respect the confidentiality of your personal and identifiable health information.

We may use your information to provide appointment reminders or to contact you concerning an appointment.

We may disclose to a family member, or any other person you identify, health information relevant to that person's involvement in your care or payment for care, or notification of your location and condition.

Other Uses and Disclosures of Personal Information. We are required to obtain written authorization form you for any other uses and disclosures of medical information other than those described above. If you provide us with such permission, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose personal information about you for the reasons covered by your written authorization, except to the extent we have already relied on your original permission.

Individual Rights. You have the right to ask for restrictions on the ways we use and disclose your health information for treatment, payment and health care operation purposes. You may also request that we limit our disclosures to persons assisting in your care or payment for your care. We will consider your request, but we are not required to accept it.

You have the right to request communications containing your protected health information form us by alternative means or at alternative locations.

Except under certain circumstances, you have the right to inspect and copy medical, billing and other records used to make decisions about you. If you ask for copies of this information, we may charge you a fee for copying and mailing.

If you believe that information in your records is incorrect or incomplete, you have the right to ask us to correct the existing information or add missing information. Under certain circumstances, we may deny your request.

You have a right to receive a list of certain instances when we have used or disclosed your medical information. We are not required to include in the list: (i) uses and disclosures for your treatment, payment for services furnished you, our health care operations, (ii) disclosures to you, (iii) disclosures you give us authorization to make and (iv) uses and disclosures before April 14, 2003, among others. If you ask for this information from us more than once every twelve months, we may charge you a fee.

You have the right to a copy of this notice in paper form. You may ask us for a copy at any time.

YOU WILL NOT BE RETALIATED AGAINST OR PENALIZED BY US FOR FILING A COMPLAINT. If you have any complaints concerning our privacy practices, you may contact the Secretary of the Department of Health and Human Services, at 200 Independence Ave., S.S., Room 509F, HHH Building, Washington, D.C. 20201 ocrmail@hhs.gov. You also may contact us by mail or telephone, attention Privacy Officer, Salem Chiropractic Center, P.C. 29 Stiles Rd., Salem, NH 03079 or telephone 603-898-0030.

To exercise any of your rights, or to obtain more information concerning this notice, you may contact our Privacy Officer at Salem Chiropractic Center, P.C. 29 Stiles Rd., Salem, NH 03079 or telephone 603-898-0030.

This notice is effective as of April 14, 2003.

We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our office in a visible location at all times, and you may request a copy of our most current Notice at any time.

Salem Chiropractic Center, P.C. | 29 Stiles Road Salem, New Hampshire 03079 | Privacy Policy
Phone: (603) 898-0030 | Fax: (603) 894-6343 | info@salemchironh.com
Weekdays: 9AM - 7PM | Saturday: 9AM - Noon