Notice of Privacy Practices

NOTICE OF PRIVACY PRACTICES

Bunge Chiropractic Health Clinic, LLC
39 Persimmon Street, Suite 603
Bluffton, South Carolina 29910
(843) 284-6959

This notice describes how your health information may be used and disclosed and how you can access this information.

PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact:

Eric L. Bunge (Clinic Privacy Officer)
Bunge Chiropractic Health Clinic, LLC
39 Persimmon Street, Suite 603
Bluffton, South Carolina 29910
(843) 284-6959

 WHO WILL FOLLOW THIS NOTICE

This notice describes the health information privacy practices followed by our clinic, the doctor, and any employees of the clinic.

YOUR HEALTH INFORMATION

This notice applies to the information and records we have about your health, your health status, and any services you receive at our clinic.

We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose this health information and our obligations regarding the use and disclosure of that information as well as a description of your rights.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment – We may use your health information to provide you with health treatment or services. We may disclose health information about you to doctors, nurses, technicians, clinic staff, or other personnel who are involved in taking care of you and your health.

Different personnel in our clinic may share information about you and disclose information to people who do not work in our clinic in order to coordinate your care, such as scheduling lab work and ordering X-rays. Family members and other health care providers may be part of your health care outside of this clinic and may require information about you that we may have.

For Payment – We may use and disclose health information about you so that the treatment and services you receive at this clinic may be billed to you and payment may be collected from you, an insurance company, or a third party, e.g., we may need to give your health plan information about a service you received here so your health plan will pay us or reimburse you for the service. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations – We may use and disclose health information about you in order to run the clinic and make sure that you and our other patients receive quality care, e.g., we may use your health information to evaluate the performance of our staff in caring for you. We may also use health information about all or many of our patients to help us decide what additional services we should offer, how we can become more efficient, or whether certain new treatments are effective.

Appointment Reminders – We may contact you as a reminder that you have an appointment for treatment or health care at the clinic.

Treatment Alternatives – We may tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health‑Related Products and Services – We may tell you about health‑related products or services that may be of interest to you.

Please notify us if you do not wish to be contacted for appointment reminders and/or if you do not wish to receive communications about treatment alternatives or health‑related products and services. If you advise us in writing at the address listed at the top of this Notice that you do not wish to receive such communications we will not use or disclose your information for these purposes.

You may revoke your Consent at any time by giving us written notice. Your revocation will be effective when we receive it; however, it will not apply to any uses and disclosures that occurred before that time.

If you do revoke your Consent, we will not be permitted to use or disclose information for purposes of treatment, payment, or health care operations, and we may therefore choose to discontinue providing you with health care treatment and services.

SPECIAL SITUATIONS

We may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:

To Avert a Serious Threat to Health or Safety – We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Required By Law We will disclose health information about you when required to do so by federal, state, or local law.

Research – We may use and disclose health information about you for research projects that are subject to a special approval process. We will ask you for your permission if the researcher will have access to your name, address, or other information that reveals who you are or will be involved in your care at the clinic.

Organ and Tissue DonationIf you are an organ donor, we may release health information to organizations that handle organ procurement, organ, eye, or tissue transplantation, or to an organ donation bank as necessary to facilitate such donation and transplantation.

Military, Veterans, National Security, and Intelligence – If you are or were a member of the armed forces or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation – We may release health information about you for worker’s compensation or similar programs. These programs provide benefits for work‑related injuries or illness.

Public Health Risks – We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non‑accidental physical injuries, reactions to medications, or problems with products.

Health Oversight Activities – We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes – If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.

Law Enforcement – We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons, or similar process, subject to all applicable legal requirements.

Coroners, Health Examiners, and Funeral Directors – We may release health information to a coroner, health examiner, or funeral director. This may be necessary, e.g., to identify a deceased person or determine the cause of death.

Information Not Personally Identifiable – We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.

Family and Friends – We may disclose health information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment, that you would not object, e.g., we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you into the exam room during treatment or while treatment is being discussed.

In situations where you are not capable of giving consent (because you are not present or due to your incapacity or health emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation we will disclose only health information relevant to the person’s involvement in your care. We may also use our professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up e.g., health supplies or X‑rays.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION

We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific written Authorization. We must obtain your Authorization separate from any Consent we may have obtained from you. If you give us Authorization to use or disclose health information about you, you may revoke that Authorization in writing at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

If we have HIV or substance abuse information about you we cannot release that information without a special signed, written authorization (different than the Authorization and Consent mentioned above), from you. In order to disclose these types of records for purposes of treatment, payment, or health care operations, we will have to have both your signed Consent and a special written Authorization that complies with the law governing HIV or substance abuse records.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy – You have the right to inspect and copy your health information, e.g., health and billing records that we use to make decisions about your care. In order to do so you must submit a written request to:

Terri Nelson-Bunge (Clinic Privacy Officer)
Bunge Chiropractic Health Clinic, LLC
39 Persimmon Street, Suite 603
Bluffton, South Carolina 29910

If you request a copy of your health information we may charge a fee for the costs associated with your request. We may deny your request to inspect and/or copy your health information in certain limited circumstances. If you are denied access to your health information you may ask that the denial be reviewed. Should such a review be required or be mandated by Federal or State law, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request and we will comply with the outcome of the review.

Right to Amend – Should you believe that your health information contained within our records is incorrect or incomplete you may submit a request to amend the alleged incorrect or incomplete information. The right to request an amendment is available as long as your health records are maintained by our clinic.

To request an amendment submit a Health Record Amendment/Correction Form to:

Terri Nelson-Bunge (Clinic Privacy Officer)
Bunge Chiropractic Health Clinic, LLC
39 Persimmon Street, Suite 603
Bluffton, South Carolina 29910

 We retain the right to deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to amend information that:

a) We did not create (unless the person or entity that created the information is no longer available to make the amendment).

b) Is not part of the records maintained at our clinic.

c) You would not be permitted to inspect and copy.

d) Is accurate and complete.

Right to an Accounting of Disclosures – You have the right to request an “accounting of disclosures.” This is a list of the disclosures we have made regarding any health information about you for purposes other than treatment, payment, and health care operations. To obtain this list, you must submit your request in writing to:

Terri Nelson-Bunge (Clinic Privacy Officer)
Bunge Chiropractic Health Clinic, LLC
39 Persimmon Street, Suite 603
Bluffton, South Carolina 29910

 Your request must state a time period (which may not be longer than six years), and may not include dates before April 14, 2003. Your request should indicate in what form you would like the list (e.g., on paper or electronically). We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions – You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, e.g., a family member or friend.

We are Not Required to Agree to Your Request – If we agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you may complete and submit the Request for Restriction on Use/Disclosure of Health Information to:

Terri Nelson-Bunge (Clinic Privacy Officer)
Bunge Chiropractic Health Clinic, LLC
39 Persimmon Street, Suite 603
Bluffton, South Carolina 29910

Right to Request Confidential Communications – You have the right to request that we communicate with you about health matters in a certain way or at a certain location, e.g., you can ask that we only contact you at work or by mail. To request confidential communications, you may complete and submit the Request For Restriction On Use/Disclosure of Health Information and/or Confidential Communication to:

Terri Nelson-Bunge (Clinic Privacy Officer)
Bunge Chiropractic Health Clinic, LLC
39 Persimmon Street, Suite 603
Bluffton, South Carolina 29910

 We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice – You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. To obtain such a copy, contact Terri Nelson-Bunge, Clinic Privacy Officer, at (843) 284-6959.

THIS NOTICE IS SUBJECT TO CHANGE

We reserve the right to change this notice and to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the clinic with its effective date in the top right hand corner. You are entitled to a copy of the notice currently in effect.

COMPLAINTS

If you believe your privacy rights have been violated you may file a complaint with our clinic or with the Secretary of the Department of Health and Human Services. To file a complaint with our clinic, contact Terri Nelson-Bunge (Clinic Privacy Officer), at (843) 284-6959. You will not be penalized for filing a complaint.

EFFECTIVE DATE OF THIS NOTICE

Please note that the effective date of this notice shall be March 26, 2013 as mandated by Federal Law and subject to change.