HIPAA Notice of Privacy Practices

Effective Date: January 04, 2022

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.

WHO WILL FOLLOW THIS NOTICE?

This Notice of Privacy Practices (the “Notice”) describes EMPOWERED CHIROPRACTIC’s practices and those of EMPOWERED CHIROPRACTIC employees, staff, volunteers, and other personnel who are involved in your care. EMPOWERED CHIROPRACTIC and these individuals will follow the terms of this Notice, and may use or disclose medical information about you to carry out treatment, payment or health care operations, or for other purposes as permitted or required by law. This Notice describes your rights to access and control medical information about you, including information that may identify you and that relates to your past, present, or future physical, medical, or mental condition and medical care and related health care services.

EMPOWERED CHIROPRACTIC’S PLEDGE REGARDING MEDICAL INFORMATION

EMPOWERED CHIROPRACTIC understands that medical information about you and your health is personal, and is therefore committed to protecting medical information about you.

For the purpose of providing, you with quality care, as well as to comply with certain state and federal legal requirements, EMPOWERED CHIROPRACTIC creates a record of the services you receive at EMPOWERED CHIROPRACTIC.

This Notice applies to all of the records of your care generated by EMPOWERED CHIROPRACTIC. This Notice will tell you about the ways in which EMPOWERED CHIROPRACTIC may use and disclose medical information about you. It also describes your rights and certain obligations EMPOWERED CHIROPRACTIC has regarding the use and disclosure of medical information. EMPOWERED CHIROPRACTIC is required by law to: (1) Make sure that medical information that identifies you is kept private; (2) Give you this Notice of its legal duties and privacy practices concerning medical information about you; (3) Follow the terms of the Notice that are currently in effect, and (4) Notify you in case there is an unauthorized use or disclosure of your unsecured medical information.

HOW EMPOWERED CHIROPRACTIC MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following categories describe different ways that EMPOWERED CHIROPRACTIC may use or disclose protected medical information. For each category of uses and disclosures, EMPOWERED CHIROPRACTIC will explain what is meant and may give some examples. Not every use or disclosure in a category will be listed. However, all of the ways EMPOWERED CHIROPRACTIC is permitted to use and disclose information will fall within one of the categories listed below.

Payment

EMPOWERED CHIROPRACTIC may use and disclose medical information about you so that payment for the treatment and services you receive at EMPOWERED CHIROPRACTIC can be received.

Operations

EMPOWERED CHIROPRACTIC may use and disclose medical information about you to carry out activities that are necessary for all operations. These uses or disclosures are made for quality of care, compliance activities, administrative purposes, contractual obligations, grievances or lawsuits. For example, EMPOWERED CHIROPRACTIC may use medical information to review treatment and services provided or to evaluate the performance of its staff and contractors in caring for you.

Individuals or Family Members & Your Health Care

Unless you object, EMPOWERED CHIROPRACTIC may disclose medical information about you to a member of your family, a relative, close friend or any other person that you identify who is involved in your care. EMPOWERED CHIROPRACTIC may also tell your family or friends, personal representative, or any other person who is responsible for your care of your location, general condition or death, unless you object.

Emergencies

EMPOWERED CHIROPRACTIC may disclose medical information about you to a public or private entity assisting in disaster relief so that your family can be notified about your condition, status, or location. You may object to this disclosure with a written request. However, if you are not available or are unable to agree or object, or in some emergency circumstances, EMPOWERED CHIROPRACTIC will use its professional judgment to decide whether this disclosure is in your best interest.

As Required By Law

EMPOWERED CHIROPRACTIC will disclose your health information when required to do so by federal, state or local law.

Workers’ Compensation

EMPOWERED CHIROPRACTIC may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Activities

EMPOWERED CHIROPRACTIC may disclose medical information about you for public health activities. These purposes generally include the following: (1) To prevent or control disease, injury, or disability; (2) To report deaths; (3) To report abuse or neglect of children, elders, and dependent adults; (4) To report reactions to medications or problems with products; (5) To notify people of recalls of products they may be using; and (6) To notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease or condition.

Health Oversight Activities

EMPOWERED CHIROPRACTIC may disclose medical information about you to a health oversight agency for activities authorized by law.

Lawsuits and Disputes

EMPOWERED CHIROPRACTIC may disclose medical information about you in response to a court or administrative order, subpoena, discovery request, or other lawful process.

Disclosure to Law Enforcement

If asked to do so by law enforcement and as authorized or required by law, EMPOWERED CHIROPRACTIC may release medical information: (1) To identify or locate a suspect, fugitive, material witness, or missing person; (2) About a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (3) About a death suspected to be the result of criminal conduct; (4) About criminal conduct at EMPOWERED CHIROPRACTIC; and (5) In case of a medical emergency, to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Decedents

EMPOWERED CHIROPRACTIC may release medical information about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. EMPOWERED CHIROPRACTIC may also release medical information about you to funeral directors. EMPOWERED CHIROPRACTIC may also release information to any individual known as a family member, close personal friend of the family, or any other person identified, who was involved in your care or the payment for your care prior to your death, unless you indicate otherwise. Your medical information may be used or disclosed to others without your authorization after fifty (50) years from the date of your death.

Specialized Government Functions

EMPOWERED CHIROPRACTIC may disclose medical information about you to authorized federal officials for intelligence, counter intelligence, and other national security activities. If you are an inmate or under the custody of a law enforcement official, EMPOWERED CHIROPRACTIC may release medical information about you to the correctional institution or law enforcement official responsible for you as authorized or required by law.

Disclosure For Threats to Health and Safety

In certain circumstances, EMPOWERED CHIROPRACTIC may be required to disclose medical information to avert a serious threat to your health and safety or the health and safety of another person as required by law enforcement. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.

Marketing

EMPOWERED CHIROPRACTIC will not release your medical information for marketing purposes without authorization from you.

Sale of Medical Information

EMPOWERED CHIROPRACTIC will not sell your medical information without authorization from you.

YOUR RIGHTS

You have the following rights regarding your medical information. In order to exercise these rights, you must contact The HIPAA Privacy Officer at EMPOWERED CHIROPRACTIC. You may be asked to submit a written request. The HIPAA Privacy Officer may be contacted using the following information:

EMPOWERED CHIROPRACTIC • UTAH CHIROPRACTOR

Attn: HIPAA Privacy Officer

Add: 913 San Ramon Valley Blvd., Suite 180, Danville, CA 94526

Phone: 925-718-5314

Email: info@empoweredchiropracticdanville.com / empowered@drmahsa.com

Right to Inspect and Copy. With certain exceptions, you have the right to inspect and receive copies of your medical information.

Amendment

If you feel that medical information about you is incorrect or incomplete, you may ask EMPOWERED CHIROPRACTIC to amend the information.

Right to an Accounting of Disclosures

You have the right to receive a list of certain disclosures that we may have made of your medical information.

Right to Request Restrictions

You have the right to request a restriction or limitation on medical information that EMPOWERED CHIROPRACTIC uses or discloses about you for treatment, payment or health care operations, and to request a limit on the medical information that EMPOWERED CHIROPRACTIC may disclose to family members or friends involved in your care.

Request Confidential Communications

You have the right to request that EMPOWERED CHIROPRACTIC communicate with you about your appointments or other matters related to your treatment in a specific way or at a specific location.

Receive a Copy

You have the right to obtain a copy of this notice.

CHANGES TO THIS NOTICE

EMPOWERED CHIROPRACTIC reserves the right to change the terms of this Notice at any time. EMPOWERED CHIROPRACTIC reserves the right to make the revised or changed notice effective for medical information about you which is currently in EMPOWERED CHIROPRACTIC’s possession, as well as any information received about you in the future. EMPOWERED CHIROPRACTIC will post a copy of the current Notice. The Notice will contain an effective date.

QUESTIONS AND COMPLAINTS

If you have any questions or believe that your privacy rights have been violated, you may contact EMPOWERED CHIROPRACTIC’s HIPAA Privacy Officer in person or mail a written summary of your concern to the address listed above.

You may also file a written complaint with the Department of Health and Human Services at the following address:

Centralized Case Management Operations

U.S. Department of Health and Human Services

200 Independence Avenue, S.W.

Room 509F HHH Bldg.

Washington, D.C. 20201

Toll-free: (800) 368-1019

TDD toll-free: (800) 537-7697

Email: OCRComplaint@hhs.gov

You will not be penalized or retaliated against for filing a complaint.

OTHER USES OF MEDICAL INFORMATION

Other uses and disclosures of medical information not covered by this Notice will be made only with your written permission. If you provide EMPOWERED CHIROPRACTIC with permission to use or disclose medical information about you, you may revoke that permission in writing at any time. If you revoke your permission, EMPOWERED CHIROPRACTIC will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if EMPOWERED CHIROPRACTIC has already acted in reliance on your permission. You understand that EMPOWERED CHIROPRACTIC is unable to take back any disclosure which has already been made with your permission and is required to retain its records of the care which has been provided to you.