Privacy

Section 7: Notice of Privacy Practices Evexia Family Chiropractic, LLC

Effective April 24, 2003 Updated: HITECH September 1, 2013

To our patients. This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Our commitment to your privacy:

Our practice is dedicated to maintaining the privacy of your health information. Evexia Family Chiropractic, LLC is required by law to maintain the confidentiality of your health information. Evexia Family Chiropractic, LLC realizes that these laws are complicated, but we must provide you with the following important information:

Use and disclosure of your health information in certain special circumstances:

Your Authorization – Except as outlined below, we will not use or disclose your PHI unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing except to the extent that we have taken action in reliance upon the authorization or that the authorization was obtained as a condition of obtaining coverage under the group health plan, and we have the right, under other law, to contest a claim under the coverage or the coverage itself.

Evexia Family Chiropractic, LLC must obtain your authorization to disclose psychotherapy notes, marketing disclosures and sale of PHI. Evexia Family Chiropractic, LLC must notify you in case of a breach of unsecured PHI.

Uses and Disclosures for Payment – We may make requests, uses, and disclosures of your PHI as necessary for payment purposes. For example, we may use information regarding your medical procedures and treatment to process and pay claims. We may also disclose your PHI for the payment purposes of a health care provider or a health plan.

Uses and Disclosures for Health Care Operations – We may use and disclose your PHI as necessary for our health care operations. Examples of health care operations include activities relating to the creation, renewal, or replacement of your health insurance coverage, reinsurance, compliance, auditing, rating, business management, quality improvement and assurance.

Family and Friends Involved in Your Care – If you are available and do not object, we may disclose your PHI to your family, friends, and others who are involved in your care or payment of a claim. If you are unavailable or incapacitated and we determine that a limited disclosure is in your best interest, we may share limited PHI with such

© ICCOM, LLC 2003, 2008, 2013 Edie Ruark Hofmann Page 26

individuals. For example, we may use our professional judgment to disclose PHI to your spouse concerning the processing of a claim.

Business Associates – At times we use outside persons or organizations to help us provide you with the best service available. Examples of these outside persons and organizations might include vendors that help us process your claims. At times it may be necessary for us to provide certain of your PHI to one or more of these outside persons or organizations.

Other Products and Services – We may contact you to provide information about other health-related products and services that may be of interest to you. For example, we may use and disclose your PHI for the purpose of communicating to you about your health and health-related products we have available to you.

Other Uses and Disclosures – We may make certain other uses and disclosures of your PHI without your authorization.

•  We may use or disclose your PHI for any purpose required by law. For example, we may be required by law to use or disclose your PHI to respond to a court order.
•  We may disclose your PHI for public health activities, such as reporting of disease, injury, birth and death, and for public health investigations
•  We may disclose your PHI to the proper authorities if we suspect child abuse or neglect; we may also disclose your PHI if we believe you to be a victim of abuse, neglect, or domestic violence.
•  We may disclose your PHI if authorized by law to a government oversight agency (e.g., a state insurance department) conducting audits, investigations, or civil or criminal proceedings.
•  We may disclose your PHI in the course of a judicial or administrative proceeding (e.g., to respond to a subpoena or discovery request).
•  We may disclose your PHI to the proper authorities for law enforcement purposes.
•  We may disclose your PHI to coroners, medical examiners, and/or funeral directors consistent with law.
•  We may use or disclose your PHI for cadaveric organ, eye or tissue donation.
•  We may use or disclose your PHI for research purposes, but only as permitted bylaw.
•  We may use or disclose PHI to avert a serious threat to health or safety.
•  We may use or disclose your PHI if you are a member of the military as requiredby armed forces services, and we may also disclose your PHI for other specialized government functions such as national security or intelligence activities.
•  We may disclose your PHI to workers’ compensation agencies for your workers’ compensation benefit determination.

© ICCOM, LLC 2003, 2008, 2013 Edie Ruark Hofmann Page 27

We will, if required by law, release your PHI to the Secretary of the Department of Health and Human Services for enforcement of HIPAA.

In the event applicable law, other than HIPAA, prohibits or materially limits our uses and disclosures of Protected Health Information, as described above, we will restrict our uses or disclosure of your Protected Health Information in accordance with the more stringent standard.

Your rights regarding your health information:

1. RighttoRequestRestrictions:RighttoRequestRestrictions:Youhavetheright to request disclosure restrictions of PHI to a health plan with respect to healthcare for which you have paid out of pocket in full where not elsewhere restricted by law.
2. Evexia Family Chiropractic, LLC is required by law to provide to you a notification of all demonstrated breaches of your PHI.
3. Communications. You can request that Evexia Family Chiropractic, LLC communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that Evexia Family Chiropractic, LLC contact you at home, rather than work. Evexia Family Chiropractic, LLC will accommodate reasonable requests.
4. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that Evexia Family Chiropractic, LLC restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. Evexia Family Chiropractic, LLC is not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
5. Youhavetherighttoinspectandobtainacopyofthehealthinformationthatmay be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to our Privacy Official: Cliff H VanBuren, DC.
6. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to our Privacy Official: Cliff H VanBuren, DC. You must provide us with a reason that supports your request for the amendment.

7. Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact our Privacy Official: Cliff H VanBuren, DC.
8. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Regional Office for Civil Rights, US Department of Health and Human Services. Regional Office information may be found online at http://www.hhs.gov/ocr/office/about/rgn- hqaddresses.html or ask the Privacy Official for the information. To file a complaint with our practice, contact our Privacy Official: Cliff H VanBuren, DC. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
9. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.

In accordance with the standards of implementation specifications of 45 C.F.R. § 164.524, Provider may grant an individual access to inspect and obtain a copy of protected health information about the individual in a designated record set.

Evexia Family Chiropractic, LLC’s policy:

1. The designated record set that is subject to access by an individual is as follows:

a. Medical Records
b. BillingRecords
c. List of all those requesting copies of designated record set

2. The titles of the persons or offices responsible for receiving and processing requests for access by individuals are as follows:
Privacy Official: Cliff H VanBuren, DC

Evexia Family Chiropractic, LLC also uses protected health information for the following reasons: (you may opt out of this authorization). Special initial authorization is required and attached.

Marketing; internal referral board, testimonials, pictures on bulletin board, sending newsletters or information unrelated to healthcare and other marketing materials.

If you have any questions regarding this notice or our health information privacy policies, please contact:  Cliff H VanBuren, DC

You can reach the Privacy Official at:

Evexia Family Chiropractic, LLC 102 NE Green Street
Lee’s Summit, Missouri, 64063
Phone number: 816-810-0234
Hours Available: A message may be left for our privacy official any time the clinic is open and your call will be returned within 7 business days.