HIPAA Chiropractic, Massage, Trigger Point Therapy, Salt Cave and more!Let us help you achieve your health goals! BOOK AN APPOINTMENT HIPAA Leave this field blank This notice describes how chiropractic and medical information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLY. In the course of your care as a patient at Kelly Family Chiropractic, we may use or disclose personal health related information about you in the following ways: "Your personal health information, including of your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment."Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer if they are or may be responsible for the payment of your services. "Your name, address, phone number, and your health care records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be on interest to you. If you are not at home to receive an appointment reminder, a message may be left on your answering machine. Further, you have the right to inspect or obtain a copy of the information we will use for these purposes. You also have the right to refuse to provide authorization, it will not affect the care provided to you or the reimbursement avenues associated with your care. Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following circumstances:"If we are providing health care services to you based on the orders of another health care provider.""If we provide health care services to you in an emergency.""If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so. "If there are substantial barriers to communicating with you, but in our judgment we believe that you intend for us to provide care.""If we are ordered by the courts or another appropriate agency.""Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization."We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or, if you would like the information in a different form, please advise us in writing as to your preferences.You have the right to inspect and/or copy your health information for seven years from the date that the record was created or as long as the information remains in our files. In addition, you have the right to request an amendment to your health information. Requests to inspect, copy or amend your health information should be provided to us in writing.We are required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice, If changes are made to our privacy notice, we will notify you in writing as soon as possible following the changes. Any change in our privacy policy will apply for all of your health information in our files.Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities, you should direct your complaint to: PATIENT PRINT NAME: PATIENT SIGNATURE: Start Drawing Clear Done Start Over Date Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 Send