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.
Our Responsibilities
The Chicago Body Works (hence, CBW) is required to maintain the privacy of your
health Information. This includes medical information about you that is collected during
the course of your treatment, such as your symptoms, examination and test results,
diagnoses, treatment, and a plan for future care. Information about care that you have
received from other providers may also be included in CBW's medical record. Health
Information also includes demographic information and payment information.
We are required by law to provide you with this Notice of Privacy Practices. This Notice
describes how we use your Health Information at CBW, and disclose (share) it with
others as necessary outside our offices. CBW must abide by the terms of the Notice
currently in effect. We reserve the right to change the terms of our Notice and to make
the new Notice provisions effective for all Health Information that it maintains. We will
post our current Notice in a prominent location in each of our practice sites, as well as
on our website: www.thechicagobodyworks.com.
Uses and Disclosures of your Health Information
The following are examples of the types of uses and disclosures of your Health
Information that CBW is legally permitted to make, as necessary, without your specific
authorization:
A. Uses and Disclosures of Health Information for Treatments, Payment and Operations
1. Treatment: Your Health Information may be used and disclosed by your chiropractor
and the CBW staff who are involved in your care and treatment. In addition, your
chiropractor or a staff member may have to disclose your health information, including
all of your clinical records, to another health care provider or a hospital if it is necessary
to refer you to them for diagnosis, assessment or treatment of your health condition.
We believe this is critical to provide you the very best in health care and is necessary,
given the complexities of various health conditions.
2. Payment: Our insurance and billing staff may use and disclose your Health
Information, as needed, to obtain payment for health care services. We may have to
disclose your examination and treatment records and your billing records to another
party, such as an insurance carrier, an HMO, a PPO or your employer, if they are
potentially responsible for the payment of your services. We may disclose information
to your insurance company or a third party payer in order to make sure your treatment
is approved, to verify eligibility or coverage for insurance benefits, and to permit the
payer to review services provided to you for medical necessity.
3. Operations: Your chiropractor and members of the staff may need to use your Health
Information, examination and treatment records and your billing records for quality
control purposes or for other administrative purposes to efficiently and effectively run
our practice.
In addition, unless you ask us not to, we will contact you to remind you of your
appointments with us. If you are not home to receive an appointment reminder, a
message will be left on your answering machine. We may also provide you with
information about treatment alternatives or other health-related benefits, products and
services that may be beneficial to you, again, with the hopes of improving your health
and welfare.
B. Other Permitted and Required Uses and Disclosures of your Health Information
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:
1. If we are providing health care services to you based on the orders of another health
care provider,
2. If we provide health care services to you as an inmate,
3. If we provide health care services to you in an emergency,
4. If we are required by law to treat you and we are unable to obtain your consent after
attempting to do so,
5. If there are substantial barriers to communicating with you, but in our professional
judgment we believe that you intend for us to provide care,
6. For reasons of Public Health, for example, to report reactions to medications or
problems with products, or that you have been exposed to a communicable disease,
7. In the course of any judicial or administrative proceeding in response to a legal order
or other lawful process, including a subpoena,
8. For law enforcement purposes
9. To a health oversight agency for audits, investigations, inspections, and other health
oversight activities,
10. To comply with Workers' Compensation laws and other programs that provide
benefits for work-related injuries
Our Privacy Pledge
CBW has always, and will always respect your privacy. Other than the uses and
disclosures we described above, we will not sell or provide any of your Health
Information to any outside marketing organization.
Your Individual Rights as a Patient
Although your medical record at CBW is the property of CBW, the Health Information it
contains belongs to you. The following are rights you have with respect to your Health
Information, and a brief description as to how you may exercise these rights.
A. Your right to revoke your authorization
You may revoke your authorization to us at any time; however, your revocation must be
in writing. There are two circumstances under which we will not be able to honor your
revocation request:
1. If we have already released your health information before we receive your request
to revoke you authorization,
2. If you were required to give your authorization as a condition of obtaining insurance,
the insurance company may have a right to your health information if they decide to
contest any of your claims.
If you wish to revoke your authorization please write to us at
The Chicago Body Works
3505 N. Ashland Ave.
Chicago, IL 60657
B. The right to limit uses or disclosures
If there are health care providers, hospitals, employers, insurers or other individuals or
organizations to whom you do not want us to disclose your health information, please
let us know, in writing, what individuals or organizations to whom you do not want us to
disclose your health care information. We are not required to agree to your restrictions.
However, if we agree with your restrictions, the restriction is binding on us. If we do not
agree to your restrictions, you may drop your request or you are free to seek care from
another health care provider.
C. Your right to receive confidential communication regarding your health information
We normally provide information about your health to you in person at the time you
receive chiropractic services from us. We may also mail you information regarding your
health or about the status of your account. We will do our best to accommodate any
reasonable request if you would like to receive information about your health or the
services that we provide at a place other than your home, or if you would like the
information in a different form. To help us respond to your needs, please make any
request in writing.
D. Your right to inspect and copy your health information
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.
We require your request to inspect and/or copy your health information to be in writing.
E. Your right to amend your Health Information
You have the right to request that we amend your Health Information for seven years
from the date that the record was created or as long as the information remains in our
files. We require your request to amend your records to be in writing and for you to give
us a reason to support the change your are requesting us to make.
F. Your right to receive an accounting of the disclosures we have made, if any, of your
Health Information
You have the right to request that we give you an accounting of the disclosures we
have made of your Health Information for the last six years before the date of your
request. The accounting will include all disclosures, except:
- those disclosures required for your treatment, to obtain payment for your
services, or to run our practice (Treatment, Payment or Operations) - those disclosures made to you
- those disclosures necessary to maintain a directory of the individuals in our
facility or to individuals involved with your care - those disclosures for national security or intelligence purposes
- those disclosures made to correctional officers or law enforcement officers
- those disclosures that were made prior to April 14, 2003, the effective date of the
HIPAA privacy law
We will provide a paper copy of this Notice to you, even if you have agreed to accept
this notice electronically.
Re-disclosure
Information that we use or disclose 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.
Your right to complain
You may complain to us or to the Secretary for Health and Human Services if you feel
that we have violated your privacy rights. We respect your right to file a complaint and
will not take any action against you if you file a complaint. While you may make an oral
complaint at any time, written comments should be addressed to:
The Chicago Body Works
Attention: Privacy Officer
3505 N. Ashland Ave.
Chicago, IL 60657
To contact us
If you would like further information about our privacy policies and practices please
contact:
The Chicago Body Works
3505 N. Ashland Ave.
Chicago, IL 60657
info@chibodyworks.com
Effective Date
This Notice is effective as of January 1, 2008.
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The Chicago Body Works, sc | 3505 N. Ashland St., Chicago, IL 60657 | (773) 248-4229
Privacy Policy