NOTICE OF PRIVACY PRACTICES

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

Tina M. Gottlieb, Chiropractic, APC is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Disclosure of Your Health Care Information

Treatment

We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. (example)

“On occasion, it may be necessary to seek consultation regarding your condition from other health care providers associated with Tina M. Gottlieb, Chiropractic, APC. Sending your x-rays to a radiologist for a second opinion is an example ”

“It is our policy to provide a substitute health care provider, authorized by Tina M. Gottlieb, Chiropractic, APC to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary health care provider's absence due to vacation, sickness, or other emergency situation."

Payment

We may disclose your health information to your insurance provider for the purpose of payment or health care operations. (example)

“As a courtesy to our patients, we will submit an itemized billing statement to your insurance carrier for the purpose of payment to Tina M. Gottlieb, Chiropractic, APC for health care services rendered. If you pay for your healtch care services personally, we will, as a courtesy, provide an itemized billing to your insurance parrier for the purpose of reimbursement to you. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the health care services recieved."

Workers’ Compensation

We may disclose your health information as necessary to comply with State Workers’ Compensation Laws.

Emergencies

We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.

Marketing.

We may contact you for marketing purposes or fundraising purposes, as described below: (example)

“As a courtesy to our patients, we may call your home on the evening prior to your scheduled appointment to remind you of your appointment time. If you are not at home, we may leave a reminder message on your answering machine or with the person answering the phone. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment. We may also contact your home in the event you have missed a scheduled appointment or we need to make a schedule change.”

"We may send a birthday card or other postcards to your home address throughout the year.”

Change of Ownership.

In the event that Tina M. Gottlieb, Chiropractic, APC is sold or merged with another organization, your health information/record will become the property of the new owner.

Your Health Information Rights
Ø You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that Tina M. Gottlieb, Chiropractic, APC is not required to agree to the restriction that you requested.

Ø You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request

Ø You have the right to inspect and copy your health information.

Ø You have a right to request that Tina M. Gottlieb, Chiropractic, APC amend your protected health information. Please be advised, however, that Tina M. Gottlieb, Chiropractic, APC is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.

Ø You have a right to receive an accounting of disclosures of your protected health information made by Tina M. Gottlieb, Chiropractic, APC

Ø You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

Changes to this Notice of Privacy Practices

Tina M. Gottlieb, Chiropractic, APC reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, Tina M. Gottlieb, Chiropractic, APC is required by law to comply with this Notice.

Tina M. Gottlieb, Chiropractic, APC is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: Tina M. Gottlieb, Chiropractic, APC by calling this office at 951-699-5161. If Tina M. Gottlieb, Chiropractic, APC is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

Complaints

Complaints about your Privacy rights, or how Tina M. Gottlieb, Chiropractic, APC has handled your health information should be directed to Tina M. Gottlieb, D.C. by calling this office at 951-699-5161. If Tina M. Gottlieb, Chiropractic, APC is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

DHHS, Office of Civil Rights

200 Independence Avenue, S.W.

Room 509F HHH Building

Washington, DC 20201

This notice is effective as of 1/20/2006.