FAMILY CHIROPRACTIC HEALTH CENTER OF LOS ALTOS
PRIVACY NOTICE

(How Your Health Information May Be Used and Disclosed
and How You Can Access That Information)

Family Chiropractic Health Center (FCHC) is committed to maintaining the privacy of your protected health information (PHI), which includes information about your health condition and the care you receive from us. The creation of a record detailing the care and services you receive helps us provide you with quality health care. This Notice details how your PHI may be used and disclosed to third parties and details your rights regarding your PHI.

1. CONSENT - FCHC may use and/or disclose your PHI provided that it first obtains a valid, signed Consent. The Consent will allow us to use and/or disclose your PHI for the purposes of:

(a) Treatment - In order to provide you with the health care you require, we will provide your PHI to those health care professionals, whether on the staff or not, directly involved in your care so that they may understand your health condition and needs. For example, your primary physician may need to know the results of your latest examination and treatment in this office.

(b) Payment - In order to get paid for services provided to you, (or for you to be reimbursed) we will provide your PHI, directly or through a billing service, to appropriate third party payors. For example, we may need to provide your insurance with information about health care services that you received from us so that you can be properly reimbursed.

(c) Health Care Operations - In order for us to operate in accordance with applicable law and insurance requirements and in order for the Practice to continue to provide quality and efficient care, it may be necessary for us to compile, use and/or disclose your PHI. For example, the Practice may use your PHI in order to evaluate the performance of the Practice's personnel in providing care to you.

2. NO CONSENT REQUIRED - We may use and/or disclose your PHI, without a written Consent from you, in the following instances:

(a) De-identified Information - Information that does not, and cannot be used to, identify you.

(b) Business Associate - To a business associate if we obtain satisfactory written assurance, he/she will appropriately safeguard your PHI. A business associate is an entity that assists FCHC in some essential function, such as a billing company that assists the office in submitting claims for payment.

(c) Emergency Situations - For the purpose of obtaining or rendering emergency treatment to you provided that we attempt to obtain your Consent as soon as possible.

(d) Communication Barriers - If, due to communication barriers, we have been unable to obtain your Consent and we determine that your Consent is clearly inferred from the circumstances.

(e) Public Health Activities - Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent or control disease.

(f) Abuse, Neglect or Domestic Violence - To a government authority if FCHC is required by law to make such disclosure. If FCHC is authorized by law to make such a disclosure, it will do so if it believes that the disclosure is necessary to prevent serious harm.

(g) Judicial and Administrative Proceeding - For example, the Practice may be required to disclose your PHI in response to a court order or a lawfully issued subpoena.

(h) Workers' Compensation - If you are involved in a Workers' Comp claim, the Practice may be required to disclose your PHI to an individual or entity that is part of the Workers' Comp system.

3. APPOINTMENT REMINDER
We may, from time to time, contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. The following appointment reminders are used by the Practice: a) a postcard mailed to you at the address provided by you; and b) telephoning your home and leaving a message on your answering machine or with the individual answering the phone.

4. FAMILY/FRIENDS
We may disclose to your family member, a close personal friend, or any other person identified by you, your PHI directly relevant to such person's involvement with your care or the payment for your care. We may also use or disclose your PHI to notify (including identifying or locating) a family member, or other person responsible for your care, of your location, general condition or death. However, in both cases, the following conditions will apply:

(a) If you are present, we may disclose your PHI if you agree, or if we can reasonably infer from the circumstances, based on our professional judgment, that you do not object to the use or disclosure.
(b) If you are not present, we will, in the exercise of professional judgment, determine whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is directly relevant to the person's involvement with your care.

YOUR RIGHTS - You have the right to:

(a) Revoke any Authorization and/or Consent, in writing, at any time. To request a revocation, you must submit a written request to Privacy Officer of FCHC.

(b) Request restrictions on certain use and/or disclosure of your PHI. However, FCHC is not obligated to agree to any requested restrictions. In your written request, you must inform us of what information you want to limit, whether you want to limit our use or disclosure, or both, and to whom you want the limits to apply. If we agree to your request, we will comply with your request unless the information is needed in order to provide you with emergency treatment.

(c) Receive confidential communications or PHI by other means or at alternative locations after submitting a written request to the Privacy Officer. We will accommodate all reasonable requests.

(d) Inspect and copy your PHI as provided by law. You must submit a written request to the Practice's Privacy Officer. We can charge you a fee for the cost of copying, mailing or other supplies associated with your request. In certain situations that are defined by law, we may deny your request, but you will have the right to have the denial reviewed as set forth more fully in the written denial notice.

(e) Amend your PHI as provided by law. You must submit a written request with a reason that supports your request. We may deny your request if it is not in writing, if you do not provide a reason, if the information to be amended was not created by us, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with the denial, you will have the right to submit a written statement of disagreement.

(f) Receive an accounting of disclosures of your PHI, after you submit a written request. The request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. The request must indicate in what form you want the list (paper or electronic copy). The first list within a twelve month period will be free. We will notify you of the costs involved for additional lists and you can decide to withdraw/modify your request before costs are incurred.

(g) Receive a paper copy of this Privacy Notice from the Practice upon request.

(h) Complain to the Practice if you believe your privacy rights have been violated. To file a complaint, you must contact the Practice's Privacy Officer. All complaints must be in writing.

(i) For more information, or questions about your rights, you may contact FCHC's Privacy Officer, Genevieve Martinez, at 949 Sherwood Avenue, Los Altos, CA or at (650) 949-3636.

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