Privacy Notice

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.

Explanation of Forms.† Feldkamp Chiropractic, Inc. handles medical information about you, and law regulates how that information is handled.† To comply with the law, Feldkamp Chiropractic, Inc. asks you to receive this notice and, in some circumstances, to sign an authorization form.

Feldkamp Chiropractic, Inc. is allowed by law to use and disclose information about you for the purposes essential to providing care (treatment, payment collection, and operating Feldkamp Chiropractic, Inc.).

An authorization allows Feldkamp Chiropractic, Inc. to use and disclose information about you for any other reason that is listed in the authorization.† Feldkamp Chiropractic, Inc. may not refuse to treat you for refusing to sign the authorization.† Other rules about your rights regarding medical information are described in this notice.

Types of Uses and Disclosures.† Medical information about you may be used or disclosed by Feldkamp Chiropractic, Inc. for treatment, payment, and health care operations.† Treatment includes consultation, diagnosis, provision of care, and referrals.† Payment includes all those things necessary for billing and collection, such as claims processing.† Health care operations include things Feldkamp Chiropractic, Inc. does to assess the quality of care, train staff, and manage Feldkamp Chiropractic, Inc.ís business.† Some examples of disclosures and use are below.

∑††††††††† Example of Treatment Disclosure.† Feldkamp Chiropractic, Inc. may disclose medical information about you to your treating physician, a hospital or other providers to help them diagnose and treat an injury or illness.

∑††††††††† Example of Payment Disclosure.† Feldkamp Chiropractic, Inc. may disclose medical information about you when health plans or insurers, Medicare, Medicaid, or other payors require the information before paying for your health care services.

∑††††††††† Example of Health Care Operations Use.† Feldkamp Chiropractic, Inc. may use medical information about you when it hires new staff whose training requires information about the medical needs of our patients.

††††††††††††††† Feldkamp Chiropractic, Inc. may also contact the patient to provide appointment reminders.

Other Uses and Disclosures. We may use or disclose your protected health information in the following situations without your authorization. These situations include:

∑††††††††† As Required By Law.† We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

∑††††††††† Public Health.† We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to another government agency that is collaborating with the public health authority.

∑††††††††† Communicable Diseases.† We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

∑††††††††† Health Oversight.† We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

∑††††††††† Abuse or Neglect.† We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

∑††††††††† Food and Drug Administration. Feldkamp Chiropractic, Inc. may disclose a patientís health information to a person subject to the jurisdiction of the Food and Drug Administration if that person has responsibility to report adverse events, product defects or problems, or biologic product deviations; to track products; to enable product recalls, repairs or replacements; or, to conduct post marketing surveillance.

∑††††††††† Legal Proceedings.† We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

∑††††††††† Law Enforcement.† We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of Feldkamp Chiropractic, Inc., and (6) medical emergency (not on Feldkamp Chiropractic, Inc.ís premises) and it is likely that a crime has occurred.

∑††††††††† Coroners, Funeral Directors, and Organ Donation.† We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out his duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

∑††††††††† Research.† We may disclose your protected health information to researchers when the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

∑††††††††† Criminal Activity.† Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

∑††††††††† Military Activity and National Security.† When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

∑††††††††† Workersí Compensation.† Your protected health information may be disclosed by us as authorized to comply with workersí compensation laws and other similar legally established programs.

∑††††††††† Inmates.† We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

∑††††††††† Required Uses and Disclosures.† Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the law.

Others Involved in Your Healthcare.† Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that personís involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Authorized Uses and Disclosures.† Additional uses and disclosure may be made if you have given written authorization, which may be revoked at any time in writing delivered to the Feldkamp Chiropractic Clinic Privacy Officer, except to the extent Feldkamp Chiropractic, Inc. acted in reliance on the authorization.

Restrictions.† You have the right to request restrictions on the use and disclosure of medical information about you; however, Feldkamp Chiropractic, Inc. will only be bound by the restrictions if Feldkamp Chiropractic, Inc. notifies you that it agrees with them.

Confidentiality.† You have the right to have Feldkamp Chiropractic, Inc. use only confidential means of communicating with you about medical information.† This means you may have information delivered to you at a certain time or place, or in a manner that keeps your information confidential.

Access.† You have the right to see and receive a copy of information about you kept by Feldkamp Chiropractic, Inc. under most circumstances.

Amendment.† You have the right to have Feldkamp Chiropractic, Inc. amend its records of information about you.† Feldkamp Chiropractic, Inc. may refuse to amend information that is accurate, that was created by someone else, or is not disclosable to you.

Accounting.† You have the right to see a list of disclosures of medical information about you by Feldkamp Chiropractic, Inc., which includes the purposes and recipients of the information.

Copy.† You have the right to receive a paper copy of this notice.

Privacy Notice.† Feldkamp Chiropractic, Inc. is required by law to keep medical information about you private and to give you this notice.† Feldkamp Chiropractic, Inc. must abide by this notice; however, Feldkamp Chiropractic, Inc. reserves the right to amend this notice and make such change applicable to all medical information maintained by Feldkamp Chiropractic, Inc..† A revised notice will be provided to patients by Feldkamp Chiropractic, Inc. by posting the new notice at 4227 Hoover Road, Grove City, Ohio 43123.

Complaints.† You may complain to Feldkamp Chiropractic, Inc. if you believe your privacy rights have been violated by giving a written complaint to Dr. Peter Feldkamp, DC at (614) 875-3338 at 4227 Hoover Road, Grove City, Ohio 43123.† You may also complain to the Secretary of the U.S. Department of Health and Human Services.† Feldkamp Chiropractic, Inc. will not retaliate against you for making a complaint.

Effective Date.† This notice is effective from April 14, 2003 until revised by Feldkamp Chiropractic, Inc.