27 Pasco Ave
Evansville, IN 47713
812-423-9146
Fax: 775-766-6516

Princeton Clinic
109 E State Street
Princeton, IN 47670
812-385-2233
Fax: 812-385-2233

Santa Claus Clinic
100 L J Koch Blvd.
Suite 201 (Middle Level)
Santa Claus, IN 47579
812-937-9883

Jasper Clinic
725 W. 6th Street
Jasper, IN 47546
812-482-4269
Important Information

HIPPA 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

UNDERSTANDING YOUR HEALTH RECORD INFORMATION

Each time you visit a hospital, physician, or healthcare provider, a record of your visit is made. Typically, this record contains you symptoms, examination and test results, diagnosis, treatment, and a plan for future care or treatment. This information often referred to as you health or medical record, serves as a basis for planning your care and treatment and serves as a means of communication among the many health professionals who contribute to your care. Understanding what is in your record and how your health information is used helps you to ensure its’ accuracy, and better understand who, what, where, and why other may access your information, and make more information decisions when authorizing disclosure to others.

YOUR HEALTH INFORMATION RIGHTS

Unless otherwise required by law, your record is the physical property of the healthcare practitioner or facility that complied it, the information belongs to you. You have the right to request a restriction on certain uses and disclosures of your information, and request amendments to your health record. This includes the right to obtain a paper copy of the notice of information practices upon request, inspect, and obtain a copy of your health record. Obtain an accounting of disclosures of your health information, request communication so your health information by alternative means or at alternative locations, revoke your authorization to use of disclose health information except to the extent that action has already been taken. Requests must be submitted in writing to the Privacy Officer (name and number listed on the last page of this notice). The practice may charge you a fee for the costs of copying, mailing, or other costs incurred by the practice in complying with your request.

OUR RESPONSIBILITY

This organization is required to maintain the privacy of your information. In addition, provide you with a notice as to our legal duties and privacy practices with respect of information we collect and maintain about you. This organization must abide by the terms of this notice, notify you if we are unable to agree to a requested restriction, accommodate reasonable request you may have to communicate health information by alternative means or at alternative location. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices changes, we will mail a revised notice to the address you’ve supplied us. If we maintain a website that provides information about our customer services or benefits we will post our new notice on that website. We will not use or disclose your health information without your authorization, except as described in this notice.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have questions and would like additional information, you may contact the Privacy Officer. If you believe your privacy rights have been violated, you can file a complaint with the Secretary of Health and Human Services. You may also provide complaints to the practice verbally or in writing. Such complaints should be directed to the practice’s Privacy Officer. There will be no retaliation for filing a complaint.

EXAMPLES OF DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH OPERATIONS

We will use your health information for treatment. For example: Information obtained by a healthcare practitioner will be recorded in your record and used to determine the course of treatment that should work best for you. By way of example, your physician will document in you record their expectation of the member of your healthcare team. Members of your healthcare team will then record the actions they took and their observation. We will also provide your other practitioners with copies of various reports that should assist them in treating you.

We will use your health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill includes information that identifies you, as well as your diagnosis, procedures, and supplies used.

We will use your health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in you health record to assess the care and outcomes in you case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Business Associates: There may be some services provided in our organization through contracts with Business Associates. Examples include physician services in the emergency department and radiology, and laboratory tests. When these services are contracted, we may disclose some or all of your health information to our Business Associate so that they can perform the job we’ve asked them to do. To protect your health information, however, we require the Business Associate to properly safeguard your information.

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.

Communication with Family: Health professionals, using their best judgment, may disclose to a family member, other relatives, close person friends or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

Additional Uses and Disclosure Permitted Without Authorization or Opportunity to Object

In addition to treatment, payment and health care operations, the practice may use or disclose your protected information without your permission or authorization in certain circumstances, including:

When Legally Required: The practice will comply with any Federal, State, or local law that requires it to disclose your protected health information.

When There Are Risks to Public Health: The practice may disclose your protected health information for public health purposes, including to, as permitted or required by law:

1. Prevent, control, or report disease, injury or disability

2. Report vital events such as birth or death

3. Conduct public health surveillance, investigations, and interventions

4. Collect or report adverse events and product defects, track FDA regulated products, enable product recalls, repairs, or replacements, and conduct post marketing surveillance.

5. Notify a person who has been exposed to a communicable disease(s) or who may be at risk of contracting or spreading a disease.

6. Report to an employer information about an individual who is a member of the workforce to the extent within the worker’s compensation laws and similar programs.

To Report Abuse, Neglect, or Domestic Violence: As required by law or with the patient’s agreement, the practice may inform government authorities if it is believed that a patient is the victim of abuse, neglect, or domestic violence.

To Conduct Health Oversight Activities: The practice may disclose your protected health information to a health oversight agency for use in 1. Audits; 2. Civil, administrative, or criminal investigations, proceedings or actions; 3. Inspections: 4. Licensure or disciplinary actions; or 5. Other necessary oversight activities as permitted by law. However, if you are the subject of an investigation the practice will not disclose protected health information that is not directly related to you receipt of health care or public benefits.

Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals. An inmate does not have the right to the Notice of Privacy Practices.

Law Enforcement: We may disclose health information for: law enforcement purposes as required by law or in response to a valid subpoena. When needed to identify or locate a suspect, fugitive, material witness, or missing person. When needed to report of crime and when you are the victim of a crime in a specific limited instance.

CONTACT PERSON

The practice's contact person regarding the practice's duties and your rights under the HIPPA privacy regulation is the Privacy Officer. The Privacy Officer can provide information regarding issues related to the Notice by request. Complaints to the practice should be directed to the Privacy Officer at the following address:

Active Chiropractic & Rehablitation Clinic
27 Pasco Ave
Evansville, IN 47713
ATTN: Dr. Reed A. Kress

EFFECTIVE DATE: This Notice is effective on April 14, 2003

A copy of this form is available upon request

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Active Chiropractic &
Rehabilitation Clinic