Notice of Privacy Practices

Khorrami Chiropractic Wellness Center — 25301 Cabot Rd Suite #106, Laguna Hills, CA 92653
Marjan Khorrami, D.C. — (949) 770-0128
Effective Date: 8-8-13

Important Notice

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.

Our Commitment to Your Privacy

We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We create and receive records to provide high-quality care, obtain payment for services, and meet our legal and professional obligations. We are required by law to protect your protected health information (PHI), to provide this Notice of our legal duties and privacy practices, and to notify you following a breach of unsecured PHI. This Notice explains how we may use and disclose your information and your rights regarding that information. Direct any questions to our Privacy Officer using the contact information above.

Table of Contents

How This Medical Practice May Use or Disclose Your Health Information
When This Medical Practice May Not Use or Disclose Your Health Information
Your Health Information Rights
— Right to Request Special Privacy Protections
— Right to Request Confidential Communications
— Right to Inspect and Copy
— Right to Amend or Supplement
— Right to an Accounting of Disclosures
— Right to a Paper or Electronic Copy of this Notice
Changes to this Notice of Privacy Practices
Complaints

A. How This Medical Practice May Use or Disclose Your Health Information

This medical practice collects health information about you and stores it in a chart and in electronic systems. The physical or electronic record is the property of this practice, but the information in it belongs to you. The law permits us to use or disclose your health information for the following purposes:

Treatment

We use and disclose medical information to provide your care. This may include sharing information with physicians, pharmacies, laboratories, or family members and others involved in your care or who can help you when you are ill, injured, or after death.

Payment

We use and disclose information to obtain payment for services we provide and to assist other providers in receiving payment for services they provided to you.

Health Care Operations

We use and disclose information to operate our practice (for example, quality assessment and improvement, staff competency, authorizations, medical reviews, legal services, audits, fraud and abuse detection, compliance, and business planning). We may share PHI with business associates (e.g., billing services) under contracts requiring them and their subcontractors to safeguard your PHI. We may also share PHI with other providers, health plans, or clearinghouses that have a relationship with you for their operations, and with organized health care arrangements (OHCAs) in which we participate.

Appointment Reminders

We may contact you to remind you of appointments. If you are not available, we may leave limited information on voicemail or with someone who answers your phone.

Sign-In and Calling Your Name

We may ask you to sign in upon arrival and may call your name when it is time to be seen.

Notification and Communication with Family

We may notify or assist in notifying a family member, personal representative, or another person responsible for your care about your location, general condition, or death, including during disasters. When feasible, we will give you an opportunity to agree or object; if you are unavailable, we will use professional judgment.

Marketing

Without payment to us, we may contact you about products or services related to your treatment, case management, or care coordination; recommend alternative treatments, providers, or settings; describe our services and health plan participation; encourage healthy behaviors or disease-management; offer nominal gifts; or tell you about government programs. We may be compensated to remind you to take or refill a currently prescribed drug or biologic. We will not otherwise use or disclose your PHI for marketing or accept payment for marketing without your written authorization. You may revoke any authorization in writing prospectively.

Sale of Health Information

We will not sell your PHI without your written authorization. Any authorization will disclose that compensation is involved and you may revoke it prospectively.

Required by Law

We will disclose PHI as required by law, limiting disclosures to what is relevant and necessary.

Public Health

We may disclose PHI to public health authorities for purposes such as disease control; reporting abuse, neglect, or domestic violence; FDA-related product issues and adverse events; and exposure notifications. We will inform you of domestic violence or elder/dependent abuse reports unless doing so would place you at risk or involve a responsible party.

Health Oversight Activities

We may disclose PHI to oversight agencies for audits, investigations, inspections, licensure, and similar activities, subject to legal limits.

Judicial and Administrative Proceedings

We may disclose PHI in response to court or administrative orders, or in response to legal process after reasonable efforts to notify you or as otherwise permitted by law.

Law Enforcement

We may disclose PHI to law enforcement for permitted purposes, such as locating a suspect or complying with legal process.

Coroners/Medical Examiners

We may disclose PHI to coroners or medical examiners as required for their duties.

Organ or Tissue Donation

We may disclose PHI to organizations involved in organ and tissue procurement, banking, or transplantation.

Public Safety

We may disclose PHI to prevent or lessen a serious and imminent threat to a person or the public.

Proof of Immunization

With your agreement (or that of a parent/guardian, as appropriate), we may disclose proof of immunization to a school that requires it for admission.

Specialized Government Functions

We may disclose PHI for military or national security purposes or to correctional institutions or law enforcement having lawful custody.

Workers’ Compensation

We may disclose PHI as necessary to comply with workers’ compensation laws, including employer or insurer reporting regarding occupational injury or illness.

Change of Ownership

If this practice is sold or merged, your PHI becomes the property of the new owner; you retain the right to request copies be sent to another provider.

Breach Notification

If your unsecured PHI is breached, we will notify you as required by law. If you provided an email address, email may be used. In some cases, a business associate may notify you.

B. When This Medical Practice May Not Use or Disclose Your Health Information

Except as described in this Notice and as permitted or required by law, we will not use or disclose identifying health information without your written authorization. If you authorize a use or disclosure, you may revoke that authorization in writing at any time, and it will apply prospectively.

C. Your Health Information Rights

You have the following rights regarding your PHI:

Right to Request Special Privacy Protections

You may request restrictions on certain uses or disclosures by written request identifying the PHI and the limitations you seek. If you pay in full out-of-pocket for an item or service and request that we not disclose related PHI to your commercial health plan, we will honor that request unless disclosure is required for treatment or by law. We may accept or reject other restriction requests and will notify you of our decision.

Right to Request Confidential Communications

You may request to receive PHI in a specific way or at a specific location (e.g., a particular email or work address). We will accommodate reasonable written requests.

Right to Inspect and Copy

You may inspect and obtain a copy of your PHI, with limited exceptions. Submit a written request describing the PHI, whether you want to inspect or copy, and your preferred form and format. If readily producible, we will provide it in that form/format; otherwise, we will offer an acceptable alternative, or if we cannot agree and we maintain it electronically, you may choose an electronic or paper copy. On written request, we will send a copy to a person you designate. We may charge a reasonable cost-based fee for labor, supplies, postage, and, if requested and agreed in advance, preparation of a summary or explanation. Certain denials carry rights to appeal or to have records sent to another professional.

Right to Amend or Supplement

If you believe PHI is incorrect or incomplete, you may submit a written request stating the reasons. We may deny your request (e.g., we did not create the information, it is not subject to inspection, or it is accurate and complete). We will explain any denial and your right to submit a written statement of disagreement; we may respond with a rebuttal. Related materials will accompany future disclosures of the disputed PHI.

Right to an Accounting of Disclosures

You may request an accounting of disclosures made by us, excluding certain disclosures (e.g., to you, with your authorization, for treatment/payment/operations, family notifications, specialized government functions, certain research/public health without direct identifiers, incidental disclosures, and certain oversight/law enforcement disclosures when notice would impede activities).

Right to a Paper or Electronic Copy of this Notice

You are entitled to a copy of this Notice and may obtain a paper copy even if you agreed to receive it electronically.

For More Information or to Exercise Your Rights

Contact our Privacy Officer using the practice contact information at the top of this Notice.

D. Changes to this Notice of Privacy Practices

We reserve the right to amend this Notice at any time. Until amended, we must follow the current Notice. After amendment, the revised Notice applies to all PHI we maintain, regardless of when created or received. We will post the current Notice in our reception area, make it available at appointments, and post it on our website.

E. Complaints

If you have concerns about our privacy practices or believe your privacy rights have been violated, contact our Privacy Officer. You may also submit a complaint to the U.S. Department of Health & Human Services, Office for Civil Rights at
OCRMail@hhs.gov.
For information about the complaint process, visit
https://www.hhs.gov/hipaa/filing-a-complaint/what-to-expect/index.html.
You will not be penalized for filing a complaint.