| At Siller Chiropractic, we are committed to
helping you find better health, naturally. Call today. Nobody can
replace you, and nothing can replace your body. We’d like to
help you keep the one you’ve got. |
| Offering: |
- Gentle, specific adjustments
- Covered by most insurance's, including Medicare
- Auto injuries accepted
- DMV & Sports physicals
- Military & Senior discounts
- Affordable payment plans
- On-site digital x-rays taken
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SILLER CHIROPRACTIC
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.
Siller Chiropractic 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 Siller Chiropractic."
"It is our policy to provide a substitute health care
provider, authorized by Siller Chiropractic 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 Siller Chiropractic for health care services rendered. If
you pay for your health care services personally,
we will, as a courtesy, provide an itemized billing
to your insurance carrier 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
received."
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.
Public Health.
As required by law, we may disclose your health information
to public health authorities for purposes related to:
preventing or controlling disease, injury or disability,
reporting child abuse or neglect, reporting domestic
violence, reporting to the Food and Drug Administration
problems with products and reactions to medications,
and reporting disease or infection exposure.
Judicial and Administrative Proceedings.
We may disclose your health information in the course
of any administrative or judicial proceeding.
Law Enforcement.
We may disclose your health information to a law enforcement
official for purposes such as identifying or locating
a suspect, fugitive, material witness or missing person,
complying with a court order or subpoena, and other
law enforcement purposes.
Deceased Persons.
We may disclose your health information to coroners
or medical examiners.
Organ Donation.
We may disclose your health information to organizations
involved in procuring, banking, or transplanting organs
and tissues.
Research.
We may disclose your health information to researchers
conducting research that has been approved by an Institutional
Review Board.
Public Safety.
It may be necessary to disclose your health information
to appropriate persons in order to prevent or lessen
a serious and imminent threat to the health or safety
of a particular person or to the general public.
Specialized Government Agencies.
We may disclose your health information for military,
national security, prisoner and government benefits
purposes.
Marketing.
We may contact you for marketing purposes or fundraising
purposes, as described below: (example)
"As a courtesy to our patients, it is our
policy to 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 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."
"It is our practice to participate in charitable events
to raise awareness, food donations, gifts, money,
etc. During these times, we may send you a letter,
post card, invitation or call your home to invite
you to participate in the charitable activity. We
will provide you with information about the type of
activity, the dates and times, and request your participation
in such an event. It is not our policy to disclose
any personal health information about your condition
for the purpose of Siller Chiropractic
sponsored fund-raising events."
Change of Ownership.
In the event that Siller Chiropractic is
sold or merged with another organization, your health
information/record will become the property of the new
owner.
Your Health Information Rights
- You have the right to request restrictions on
certain uses and disclosures of your health information.
Please be advised, however, that Siller Chiropractic is not required to agree to the restriction
that you requested.
- 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.
- You have the right to inspect and copy your health
information.
- You have a right to request that Siller Chiropractic amend your protected health information.
Please be advised, however, that Siller Chiropractic 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.
- You have a right to receive an accounting of disclosures
of your protected health information made by Siller Chiropractic.
- 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
Siller Chiropractic 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, Siller Chiropractic is required
by law to comply with this Notice.
Siller Chiropractic 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: Marilyn Xavier by calling this office
at 707-996-4535. If Marilyn Xavier 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 Siller Chiropractic has handled your health information should
be directed to Marilyn Xavier by calling this office
at 707-996-4535 If Marilyn Xavier 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 ______/______/_______
I have read the Privacy Notice and understand my rights
contained in the notice.
By way of my signature, I provide Siller Chiropractic with my authorization and consent to use
and disclosed my protected health care information for
the purposes of treatment, payment and health care operations
as described in the Privacy Notice.
________________________________________________
Patient’s Name (print)
________________________________________________
______________
Patient’s Signature
Date
________________________________________________
______________
Authorized Facility Signature
Date
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