Reform Chiropractic - 612 E Longview Drive, Appleton WI 54911 Kaylee Harris D.C. - (920) 224-5362
Effective Date: 07-28-2023

THIS NOTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USE AND DISCLOSED HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We understand the importance of maintaining your privacy and confidenJality of you protected health informaJon. The terms of this NoJce of Privacy Pracicces (“Notice”) apply to Reform Chiropractic and its employees. Reform Chiropractic will share protected health information of patient as necessary to carry out treatment, payment, and health care operations as permitted by law.

How Reform Chiropractic LLC May Use and Disclose Your Protected Health Information:

Except as outlined below, we will not use or disclose your protected health information for any purpose other than treatment, payment of health care operations unless you have signed a form authorizing use and disclosure.

Treatment – We use and disclose your protected health information as necessary for treatment. Information is disclosed to our employees and other providers who may be involved in your care. Other professionals may need access to your records and information to understand your treatment within our clinic before they provide their necessary treatments and/or testing. We may share information with family members or your emergency contact if you are sick or injured, or after you die.

Payment – We use and disclose your protected health information as necessary for payment purposes. We may provide your insurance company with information regarding your procedures and treatment to arrange payment for the services provided to you. We may use your information to prepare a bill to send to you or the person responsible for your payment.

Health Care Operations - We use and disclose your protected health information as necessary for health care operations. Your information may used to improve quality of care provided by our staff and professionals. We may use your information for referrals. We may use information for medical reviews, business management including legal services and audits. We may share your information with other providers, health care clearinghouses or health plans that have a relationship with you.

Appointment Reminders – We use and disclose your protected health information to contact you and remind you of upcoming appointments. We may leave a voice message on your answering machine or leave a message with the individual answering the phone. We may send text message and email reminders.

Checking in at the Office – We use and disclose your protected health information as necessary when you arrive to our office. We may call out your name when we are ready to see you.

Notification and Communica?on with Family - We use and disclose your protected health informaJon as necessary with a family member, personal representative, or other individual responsible for your care. If you are unavailable, incapacitated or facing an emergency; we will determine that a limited disclosure may be in your best interest and way may share information with such individuals without your approvals. We may disclose limited protected health information to a public or private entity in the event of a disaster in order for that enJty to locate a family member or other individuals that may be involves in some aspect of caring for you. If you are available and able to agree or object, we will give you the opportunity to object prior to making these decisions, although we may disclose this information even over your objection if we believe it is necessary to respond in emergency circumstances. If you are unavailable or unable to agree or object, we will use our best judgement in communication with your family or others responsible for your care​

Marketing - We use and disclose your protected health informaJon as necessary for marketing purposes. We may contact you to give information about products, services or resources related to your treatment. We may describe products or services provided by Reform Chiropractic. We may send information encouraging a healthy lifestyle, about maintaining wellness, and about preventative care.

​Sale of Health Information - We will not sell your health information with your prior written authorization. We must obtain your authorization prior to receiving any compensation for your health information. This may include public health activities, research purposes, or health care operations involving the sale, transfer, merger, or consolidation of all or part of our business, disclosures required by law such as when the law requires us to report abuse, neglect, or domestic violence, or to respond to judicial or administrative proceeding, or law enforcement officials.

Public Health - We use and disclose your protected health information as necessary for public health purposes. We may be required by law to disclose your information to public health authorities for the purposes of disease prevents and control, disease or infection exposure; reporting child, elder or dependent adult abuse or neglect, or reporting medication reactions to the Food and Drug Administration.

Judicial and Administrative Proceedings - We use and disclose your protected health information as necessary for judicial and administrative proceedings. We may be required by law to disclose your information for any judicial or administrative proceedings. We may disclose information in response to a subpoena, discovery request, or other lawful processes if efforts have been made to noJtify you of the request and you have not objected or if you objections have been resolved by the court or administrative order.

Law Enforcement - We use and disclose your protected health information as necessary with law enforcement. We may be required by law to share your information with law enforcement for purposes including identifying or locating a suspect, witness, missing person, or fugitive. We may share your information in order to prevent a serious and imminent threat to the health and safety of the general public or individual person.

Workers’ Compensation - We use and disclose your protected health information as necessary to comply with workers compensation law. We will make reports to your employer about your condition. We are required by law to report cases of occupational injury or illness to the employer or workers compensation insurer.

Your Rights Regarding Your Protected Health information:

Right to Access Your Protected Health Information – You have the right to copy and/or inspect much of your protected health information that we retain. Reform Chiropractic maintains health records in a digital format. You must submit a written request detailing what information you want access to, your preferred format and the request must be signed by you. You may obtain a “Patient Access to Health Information” form from Reform Chiropractic. We will provide copies in your preferred format if it readily producible, otherwise we will provide you with an alternative that you find acceptable. We may also send copies to any other person you designate in writing. You will be charged a reasonable fee for supplies, postages, and copying. We may deny your request under limited circumstances.

​Right to Amend or Supplement – You have the right to request in writing that protected health information that we maintain be amended or corrected. If you believe information is incorrect or incomplete, you must make a request in writing and include the reasons for the request and/or why you believe the information to be inaccurate. We are not required to change your information and will provide you with written explanation of our denial. We may deny your request if we did not have the information, if we did not create the information, or if the information is accurate and complete.

Right to an Accounting of Disclosures – You have the right to receive an accounting of disclosures make by use of your protected health information. Request must be made in writing and sign by you. Reform Chiropractic does not have to account for the disclosures provided to you as described in paragraphs treatment, payment, health care operaJons, notifications and communication with family, and law enforcement stated earlier in this notice.

Right to Request Restriction on Use and Disclosure of Your Protected Health Information – You have the right to request restriction on use and disclosure of your protected health information by providing a written request. The request must specify what information you would like to limit and what the limitations are on our use or disclosure of that information. We will attempt to accommodate reasonable requests unless we must disclose information for legal reasons. We reserve the right to accept or object such requests and will notify you of our decision.

Right to Confidential Communications – You have the right to receive communication in a specific way or at a specific location. We will attempt to accommodate reasonable requests submitted in a written request. The request must specify how or where you wish to receive communications from Reform Chiropractic.

Right to Notice of Breach - We take very seriously the confidentiality of our patients’ information, and we are required by law to protect the privacy and security of your protected health information through appropriate safeguards. We will notify you in the event a breach occurs involving or potentially involving your unsecured health information and inform you of what steps you may need to take to protect yourself.

Right to a Paper or Electronic Copy of this Notice – You have a right to obtain a paper copy of this Notice even if you have agreed to receive notices electronically.​

If you would like to exercise one or more of these rights, contact our Privacy Officer listed at the top of this Notice of Privacy Practices.

Changes to This Notice of Privacy Practices 

We have the right to amend this Notice at any Jme. Until an amendment is made, we are required to comply with the terms of the Notice currently in effect. If an amendment is made it will apply to all protected health informaJon that we maintain, regardless of when it was created or received. We will keep a copy of the current Notice in our office. Our current Notice will also be available to view on our website.

Complaints

If you believe your privacy rights have been violated, you can file a complaint in writing with the Privacy Officer listed at the top of this Notice of Privacy Practices. If you are not satisfied with the manner in which Reform Chiropractic handle a complaint, you may submit a formal complaint with the Secretary of the U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint.

The complaint form may be found at: www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf. You will not be penalized in any way for filing a complaint.