NOTICE OF PRIVACY PRACTICES

YOUR INFORMATION. YOUR RIGHTS. OUR RESPONSIBILITES.

This notice is effective January 1, 2022 and describes how Boots Chiropractic & Wellness Center, S.C. may use and disclose Protected Health Information (PHI) to carry out treatment, payment or heath care operations, and for other purposes that are permitted or required by law and how you can get access to this information. Please review it carefully.

Any questions regarding this Privacy Notice should be directed to the Boots Chiropractic & Wellness Center, S.C. Privacy Officer, who can be reached at 920-997-9700.

YOUR RIGHTS – you have the right to:

• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

YOUR CHOICES – you have some choices in the way we use and share information:

• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services
• Raise funds

OUR USES AND DISCLOSURES – we may use and share your information as we:

• Treat you
• Run our organizations
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medial examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

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YOUR RIGHTS

When it comes to your health information, you have certain right. This section explains your rights and some of our responsibilities to help you.

• Get an electronic or paper copy of your medical record
  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
• Ask us to correct your medical record
  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we’ll tell you why in writing within 30 days.
• Request confidential communications
  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • We will say “yes” to all reasonable requests.
• Ask us to limit what we use or share
  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
• Get a list of those with whom we’ve shared information
  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
• Get a copy of this privacy notice
  • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notices electronically. We will provide you with a paper copy promptly.
• Choose someone to act for you
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action.
• File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting Boots Chiropractic & Wellness Center, S.C.’s Privacy Officer identified on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/oer/privacy/hipaa/...
• We will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

• In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

• In these cases, we never share your information unless you give us written permission:
  • Marketing purposes
  • Sale of your information
  • Most sharing of psychotherapy notes
• In the case of fundraising:
  • We may contact you for fundraising efforts, but you can tell us not to contact you again.

OUR USES AND DISCLOSURES

1.1       How do we typically use or share your health information?

We typically use or share your health information in the following ways:

• Treat you
  • We can use your health information and share it with other professionals who are treating you.
    • Example: A doctor treating you for an injury asks another doctor about your overall health condition. 
• Run our organization
  • We can use and share your health information to run our practice, improve your care, and contact you when necessary.
    • Example: We use health information about you to manage your treatment and services.
• Bill for your services
• We can use and share your health information to bill and get payment from health plans or other entities.
• Example: We give information about you to your health insurance plan so it will pay for your services. 

1.2       How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/...

• Help with public health and safety issues.
  • We can share health information about you for certain situations such as:
    • Preventing disease
    • Helping with product recalls
    • Reporting adverse reactions to medications
    • Reporting suspected abuse, neglect, or domestic violence
    • Preventing or reducing a serious threat to anyone’s health or safety
• Do research
  • We can use or share your information for health research
• Comply with the law
  • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
• Respond to organ and tissue donation requests
  • We can share health information about you with organ procurement organizations.
• Work with a medical examiner or funeral director
  • We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
• Address workers’ compensation, law enforcement, and other government requests
  • We can use or share health information about you:
    • For worker’s compensation claims
    • For law enforcement purposes or with a law enforcement official
    • With health oversight agencies for activities authorized by law
    • For special government functions such as military, national security, and presidential protective services
• Respond to lawsuits and legal actions
  • We can share health information about you in response to a court or administrative order, or in response to a subpoena

1.3       How is protected health information used for marketing purposes?

We never sell personal information but from time to time our practice would like to make you aware of products or services that you may have interest in. This marketing could be done by our internal staff or by an outside marketing organization. Your health information including your name, address, and phone number may be used for the purpose of marketing products and services from Boots Chiropractic & Wellness Center, S.C. to you.

We are specifically requesting authorization to market the following products and/or services to you:

• Sending greeting cards acknowledging birthdays, anniversaries, and complimentary/discounted services.
• Sending thank-you letter to the friend or family member that referred you to our office.
• Mailing letter, postcards, text messaging, or phoning you as part of our recall program.
• Text messaging and phone call visit reminders.
• Displaying your holiday cards, acknowledging your birthday, the use of pictures for a “kids wall”, the use of your name on a thank-you board, and requesting donations from you for charitable causes in our office/waiting room.
• To undergo treatment that is part of a research project or to use treatment as a case study.
• Sending marketing materials to you and use of your name in advertising informing you of special activities.

We are specifically requesting authorization for the use of the following:

• Public use of your name, picture, testimonial and review. Use of your information in our office and on our website, Facebook page, and other social media forms. 

You may restrict the individuals or organizations to which your health care information is released or revoke your authorization to us at any time; however, your revocation must be in writing and mailed to us at our office address. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.

Information that we use or disclose based on the authorization you are giving us may be subject to re-disclosure by the organization/s listed above and may no longer be protected by federal privacy rules. You have the right to refuse to give us this authorization. If you do not give us permission, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care. You may inspect or copy the information that we use to contact you for marketing purposes at any time. Our practice and staff will receive direct or indirect remuneration from our marketing activities.

OUR RESPONSIBILITIES

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it upon request.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/...

CHANGES TO THE TERMS OF THIS NOTICE

• We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request to our patients in our office.
• Changes may be made to without notice.

CONTACT INFORMATION

Phone – 920-997-9700

Fax – 920-997-0060

Mail – 1020 Truman St. Suite B, Kimberly, WI 54136

E-mail – [email protected]

Website – www.BootsChiropractic.com

Facebook – www.facebook.com/BootsChiropra...