Section 7: Notice of Privacy Practices
Northern Pine Chiropractic Center
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. Northern Pine Chiropractic Center is required by law to maintain the confidentiality of your health information. Northern Pine Chiropractic Center 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 laws, to contest the claim under the coverage or the coverage itself. Northern Pine Chiropractic Center must obtain your authorization to disclose psychotherapy notes, marketing disclosures, and the sale of PHI. Northern Pine Chiropractic Center 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 creating, renewing, or replacing 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 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 this 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 to communicate 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, nor 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
- 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 the 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 by law.
- 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 required
by armed forces services, and we may also disclose your PHI for other specialized government functions such as national security or intelligence
- We may disclose your PHI to workers’ compensation agencies for your workers’ compensation benefit determination.
- 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 disclosures of Protected Health Information, as described above, we will restrict our uses or disclosure of your Protected Health Information by the more stringent standard.
Your rights regarding your health information:
- Right to Request Restrictions: Right to Request Restrictions. You have to request disclosure restrictions of PHI to a health plan concerning healthcare for which you have paid out of pocket in full where not elsewhere restricted by law.
- Northern Pine Chiropractic Center is required by law to provide you a notification of all demonstrated breaches of your PHI.
- Communications. You can request that Northern Pine Chiropractic Center communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that Northern Pine Chiropractic Center contacts you at home, rather than at work. Northern Pine Chiropractic Center 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 Northern Pine Chiropractic Center restrict our disclosure of your health information to only certain individuals involved in your care or the pament
for your care, such as family members and friends. Northern Pine Chiropractic Center 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.
- You have the right to inspect and obtain a copy of the health information that may 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: Chris Ketchmark.
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: Chris Ketchmark You must provide us with a reason that
supports your request for the amendment.
- 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: Chris Ketchmark.
- 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:
or ask the Privacy Official for the information. To file a complaint with our practice, contact our Privacy Official Chris Ketchmark. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
- Right to provide 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.
By the standards of implementation specifications of 45 C.F.R 164.524, Provider may grant individual access to inspect and obtain a copy of
protected health information about the individual in a designated record set.
Northern Pine Chiropractic Center’s policy:
1. The designated record set that is subject to access by an individual is as follows:
a. Medical Records
b. Billing Records
c, List of all those requesting copies of a designated record set
- The titles of the persons or offices responsible for receiving and processing requests for access by individuals are as follows:
Privacy Official: Chris Ketchmark
Northern Pine Chiropractic Center 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:
You can reach the Privacy Official at:
Northern Pine Chiropractic Center PO Box 139
Sandstone, MN 55072
Phone number: 2183728197
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.