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CASAZZA CHIROPRACTIC GROUP
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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.
CASAZZA CHIROPRACTIC GROUP is required, by law, to
maintain the privacy and confidentiality of your protected health information
and to provide our patients with notice of our legal duties and privacy
practices with respect to your protected health information.
Disclosure of Your
Health Care Information
Treatment
We
may disclose your health care information to other healthcare professionals
within our practice for the purpose of treatment, payment or healthcare
operations.
"On occasion, it may be necessary
to seek consultation regarding your condition from other health care
providers associated with Casazza Chiropractic Group."
"It is our policy to provide
a substitute health care provider, authorized by Casazza Chiropractic
Group to provide assessment and/or treatment to our patients, without
advanced notice, in the event of your primary health care provider's
absence due to vacation, sickness, or other emergency situation.
Payment
We may disclose your health information to your
insurance provider for the purpose of payment or health care operations.
"As a courtesy
to our patients, we will submit an itemized billing statement to your
insurance carrier for the purpose of payment to Casazza Chiropractic
Group for health care services rendered.
If you pay for your health care services personally, we will,
as a courtesy, provide an itemized billing to your insurance carrier
for the purpose of reimbursement to you. The billing statement contains
medical information, including diagnosis, date of injury or condition,
and codes which describe the health care services received."
Workers' Compensation
Casazza
Chiropractic Group may disclose your health information as necessary
to comply with State Workers' Compensation Laws.
Emergencies
We
may disclose your health information to notify or assist in notifying
a family member, or another person responsible for your care about your
medical condition or in the event of an emergency or of your death.
Public Health
As required by law, we may
disclose your health information to public health authorities for purposes
related to: preventing or controlling
disease, injury or disability, reporting child abuse or neglect, reporting
domestic violence, reporting to the Food and Drug Administration problems
with products and reactions to medications, and reporting disease or
infection exposure.
Judicial
and Administrative Proceedings.
We may disclose your health
information in the course of any administrative or judicial proceeding.
Law
Enforcement.
We may disclose your health
information to law enforcement officials for purposes such as identifying
or locating a suspect, fugitive, material witness or missing person,
complying with a court order or subpoena, and other law enforcement
purposes.
Deceased
Persons.
We may disclose your health
information to coroners or medical examiners.
Organ
Donation.
We may disclose your health
information to organizations involved in procuring, banking, or transplanting
organs and tissues.
Research.
We may disclose your health
information to researchers conducting research that has been approved
by an Institutional Review Board.
Public
Safety.
It
may be necessary to disclose your health information to appropriate
persons in order to prevent or lessen a serious and imminent threat
to the health or safety of a particular person or to the general public.
Specialized
Government Agencies.
We may disclose your health information for military,
national security, prisoner and government benefits purposes.
Marketing.
We may contact you for marketing purposes or fundraising
purposes, as described below:
"As a courtesy to our patients,
it is our policy to call your home on the evening prior to your scheduled
appointment to remind you of your appointment time. If you are not at
home, we leave a reminder message on your answering machine or with
the person answering the phone. No personal health information will
be disclosed during this recording or message other than the date and
time of your scheduled appointment along with a request to call our
office if you need to cancel or reschedule your appointment."
"It is our practice to participate
in charitable events to raise awareness, food donations, gifts, money,
etc. During these times, we may send you a letter, post card, invitation
or call your home to invite you to participate in the charitable activity. We will provide you with information about the
type of activity, the dates and times, and request your participation
in such an event. It is not our
policy to disclose any personal health information about your condition
for the purpose of Casazza Chiropractic Group sponsored fund-raising
events."
Change
of Ownership.
In the event that Casazza
Chiropractic Group is sold or merged with another organization,
your health information/record will become the property of the new owner.
Your Health Information Rights
Ø
You have the right to request restrictions
on certain uses and disclosures of your health information. Please be advised, however, that Casazza Chiropractic
Group is not required to agree to the restriction that you requested.
Ø
You have the right to have your health information
received or communicated through an alternative method or sent to an
alternative location other than the usual method of communication or
delivery, upon your request.
Ø
You have the right to inspect and copy your
health information.
Ø
You have a right to request that Casazza Chiropractic
Group amend your protected health information. Please be advised, however,
that Casazza Chiropractic Group is not required to agree to amend your
protected health information. If your request to amend your health information
has been denied, you will be provided with an explanation of our denial
reason(s)and information about how you can
disagree with the denial.
Ø
You have a right to receive
an accounting of disclosures of your protected health information made
by Casazza Chiropractic Group.
Ø
You have a right to a paper copy of this Notice
of Privacy Practices at any time upon request.
Changes to this Notice of Privacy Practices
Casazza Chiropractic Group reserves
the right to amend this Notice of Privacy Practices at any time in the
future, and will make the new provisions effective for all information
that it maintains. Until such amendment is made, Casazza Chiropractic
Group is required by law to comply with this Notice.
Casazza Chiropractic Group
is required by law to maintain the privacy of your health information
and to provide you with notice of its legal duties and privacy practices
with respect to your health information.
If you have questions about any part of this notice or if you want
more information about your privacy rights, please contact: Ms. Julie
Forrest, by calling this office at (916) 447-2200. If Ms. Julie
Forrest is not available, you may make an appointment for a personal
conference in person or by telephone within 2 working days.
Complaints
Complaints about your Privacy
rights, or how Casazza Chiropractic Group has
handled your health information should be directed to Ms. Julie Forrest,
by calling this office at (916) 447-2200. If Ms. Julie Forrest is not
available, you may make an appointment for a personal conference in
person or by telephone within 2 working days.
If you are not satisfied with the manner in which
this office handles your complaint, you may submit a formal complaint
to
DHHS, Office of Civil Rights
Room 509F
This notice is effective as of
I have read the Privacy Notice and understand my rights
contained in the notice.
By way of my signature, I provide Casazza Chiropractic
Group with my authorization and consent to use and disclosed my protected
health care information for the purposes of treatment, payment and health
care operations as described in the Privacy Notice
________________________________________________
Patient's Name (print)
________________________________________________ ______________
Patient's Signature
Date
________________________________________________ ______________
Authorized Facility Signature Date
Casazza Chiropractic
2716 V street, Sacramento CA 95818
Office: (916) 447-2200 - Fax (916) 447-7930
Email Dr. Casazza: doctorlance@hotmail.com
Mon-Tue., Thu-Fri. 9:00 a.m. - 6:00 p.m.
Wed. 8:00 a.m. - 6:00 p.m.
