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Marshall Family Chiropractic

1605 Fred Moore Hwy - St. Clair   810-329-6100

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.

Here are some examples of how we might have to use or disclose our health care information: 

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.

Our insurance and billing staff 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.  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 his/her practice.  Your chiropractor and members of the practice staff may need to use your name, address, phone number and your clinical records to contact you to provide appointment reminders, information about treatment alternatives or other health related information that may be of interest to you. If you are not at home to receive an appointment reminder, a message will be left on your answering machine.

You have the right to refuse to give us authorization to contact you to provide appointment reminders, information about treatment alternatives or other health related information. If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.

You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives or other health related information at any time. 

Our Privacy Pledge

We have and always will respect your privacy. Other than the uses and disclosures we described above.

We will not sell of provide any of your health information to any outside marketing organization.

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:

We are permitted to use or disclose your health information if we are providing health care services to you based on the orders of another health care provider.  We are permitted to use or disclose your health information if we provide health care services to you as an inmate.

Other than the circumstances described in the preceding five examples, any other use or disclosure of your health information will only be made with your written authorization.

You may revoke your authorization to us at nay time; however, your revocation must be in writing. There are two circumstances under which we will not be able to honor your revocation request: 

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.

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.

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.

 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 you are requesting us to make.

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.

 - 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 the effective date of the HIPPA privacy law.

We will provide the first accounting within any 12-month period without charge. There is a fee for any additional requests during the next 12 months. When you make your request we will tell you the amount of the fee and you will have the opportunity to withdraw or modify your request.

If you have agreed to receive privacy notices by e-mail, you may request a paper copy of this notice at any time.

We are required by law to maintain the privacy of your health information. We are also required to provide you with this notice of our legal duties and our privacy practices with respect to your health information.

We must abide by the terms of this notice while it is in effect. However, we reserve the right to change the terms of our privacy notices. If we make a change to the terms of our privacy agreement we will notify you in writing when you come in for treatment or by mail. If we make a change in our privacy terms the change will apply for all of your health information in our files. 

Re-disclosures

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.

You may complain to us or to the Secretary of 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:

If you would like further information about our privacy policies and practices, please contact:

Marshall Family Chiropractic

1605 Fred Moore Hwy

St. Clair, MI 48079

(810) 329-6100

This notice is effective as of ___________________________. This notice will expire seven years after the date upon which the record was created. By signing below, I acknowledge that I have received a copy of this notice.

________________________________                   ________________________________

Patient Name                                                                         Printed Date

________________________________                 _________________________________

Patient Signature                                                                 Authorized Provider Representative

________________________________                 _________________________________

Personal Representative Printed                                     Personal Representative Signature

Description of personal representative's authority to act for the patient

Under federal law, we are also permitted or required to use or disclose your health information in these following circumstances.  We are permitted to use or disclose your health information if we are providing health care services to you based on the orders of another health care provider.  We are permitted to use or disclose your health information if we provide health care services to you as an inmate.  We are permitted to use or disclose your health information if we provide health care services to you in an emergency.  We are permitted to use or disclose your health information if we are required by law to treat you and we are unable to obtain your consent after attempting to do so.  We are permitted to use or disclose your health information if there are substantial barriers to communicating with you, but in our professional judgement we believe that you intend for us to provide care.

Other than the circumstances described in the preceding five examples, any other use or disclosure of your health information will only be made with your written 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.

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 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.

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.

You have the right to inspect and/or copy your health information for seven years from the date that the record was created. We require your request to inspect and/or copy your health information to be in writing.

You have the right to request that we amend your health information for seven years from the date that the record was created. We require your request to amend your records to be in writing and for you to give us a reason to support the change you are requesting us to make.

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 required for your treatment, to obtain payment for your services, or to run our practice.

We will provide the first accounting within any 12 month period without charge. There is a fee for any additional requests during the next 12 months. When you make your request we will tell you the amount of the fee and you will have the opportunity to withdraw or modify your request.

If you have agreed to receive privacy notices by e-mail, you may request a paper copy of this notice at any time.

We are required by law to maintain the privacy of your health information. We are also required to  provide you with this notice of our legal duties and our privacy practices with respect to your health information.  We must abide by the terms of this notice while it is in effect. However, we reserve the right to change the terms of our privacy notices. If we make a change to the terms of our privacy agreement we will notify you in writing when you come in for treatment or by mail. If we make a change in our privacy terms the change will apply for all of your health information in our files.

Information that we use or disclose based on the authorization you are giving us 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.

If you would like further information about our privacy policies and practices please contact:

1605 Fred Moore Hwy

St. Clair, MI 48079

This notice is effective as of _______________________. This notice will expire seven years after the date upon which the record was created. By signing below, I acknowledge that I have received a copy of this notice.

____________________________                         ____________________________

Patient Name                                                                     Printed Date

____________________________                         ____________________________

Patient Signature                                                             Authorized Provider Representative

____________________________                         _____________________________

Personal Representative Printed                                 Personal Representative Signature

Description of personal representative’s authority to act for the patient.

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

WITH FUND RAISING PROVISION

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 CAREFULLY.

Here are some examples of how we might have to use or disclose your health care information:

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.  Our insurance and billing staff may have to disclose your examination and treatment records and your billing records to another party, such as an insurance carrier, and HMO, a PPO, or your employer if they are potentially responsible for the payment of your services.

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.

Your chiropractor and members of the practice staff may need to use your name, address, phone number and your clinical records to contact you to provide appointment reminders, information about treatment alternatives or other health related information that may be of interest to you. If you are not at home to receive an appointment reminder, a message will be left on your answering machine. 

You have the right to refuse to give us authorization to contact you to provide appointment reminders, information about treatment alternatives or other health related information. If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.

You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives or other health related information at any time.

From time to time our practice raises money for chiropractic causes. We may need to use your health information including your name, address, phone number and your clinical records to contact you to request your assistance with these fund raising efforts. The authorization form you sign for this purpose contains the name of the organization for whom we are raising money.

You have the right to refuse to give us authorization to contact you for fund raising purposes. If you do not give us permission, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.

You may inspect or copy the information that we use to contact you about fund raising efforts at any time. Our practice and staff will receive direct or indirect remuneration from our fund raising activities.

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:

Other than the circumstances described in the preceding five examples, any other use or disclosure of your health information will only be made with your written 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.

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 this 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.

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.

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.

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 you are requesting us to make.

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.

- 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 the effective date of the HIPPA privacy law,

We will provide the first accounting within any 12-month period without charge. There is a fee for any additional requests during the next 12 months. When you make your request we will tell you the amount of the fee and you will have the opportunity to withdraw or modify your request.

If you have agreed to receive privacy notices by e-mail, you may request a paper copy of this notice at any time.

We are required by law to maintain the privacy of your health information. We are also required to provide you with this notice of our legal duties and our privacy practices with respect to your health information.  We must abide by the terms of this notice while it is in effect. However, we reserve the right to change the terms of our privacy notices. If we make a change to the terms of our privacy agreement, we will  notify you in writing when you come in for treatment or by mail. If we make a change in our privacy terms, the change will apply for all of your health information in our files.

Information that we use or disclose based on the authorization you are giving us 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.

You may complain to us or to the Secretary of 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:

If your would like further information about our privacy policies and practices please contact:

1605 Fred Moore Hwy

St. Clair, MI 48079

This notice is effective as of _________________________. This notice will expire seven years after the date upon which the record was created. By signing below, I acknowledge that I have received a copy of this notice.

________________________________                             ______________________________

Patient Name                                                                                 Printed Date

________________________________                             ______________________________

Patient Signature                                                                         Authorized Provider Representative

________________________________                             _______________________________

Personal Representative Printed                                                 Personal Representative Signature

Description of personal representative’s authority to act for the patient.

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Contact Information

Marshall Family Chiropractic

FAX 810-329-8650

Address 1605 Fred Moore Hwy - St. Clair, MI 48079

Send mail to drmarshall@marshallchiro.com with questions or comments about this web site.
Last modified: 02/29/08