Privacy

In the course of your care as a patient at Koch Chiropractic we may use or disclose personal and health related information about you in the following ways:

• Your personal health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
• Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, and HMO, a PPO, or your employer, if they are or may be responsible for the payment of your services.
• In the course of your care we will be delivering your care in an open bay environment. Information of your condition and care/financial discussions may be disclosed to other patients or staff in the approximate vicinity of where your care is being delivered. We cannot assure that any of the details of your care will be addressed and considered as confidential by other patients.
• Your name, address, phone number, work phone number, and your health care records may be used to contact you regarding appointment reminders, missed appointments, birthday wishes, recalls, special occasions/events, health care products, information about alternatives to your present care, 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 may be left on your answering machine. Further, you have the right to inspect or obtain a copy of the information we will use for these purposes. You also have the right to refuse to provide authorization for this office to contact you regarding these matters. If you do not provide us with this authorization it will not affect the care provided to you or the reimbursement avenues associated with your care.
• Your name may be used in our office for a signature sheet in regards to keeping scheduled appointments, thank you notes when one refers another patient/person into our office, for hands/or pictures posted in our office, and/or testimonials from you in writing to inform other patient's of chiropractic results, and for special events/fun days in our office when gifts are given out.

• If we are providing health care services to you based on the orders of another health care provider.
• If we provide health care services to you in an emergency.
• If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so.
• If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
• If we are ordered by the courts or another appropriate agency. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization.

You have the right to inspect and/or copy your health information for six years from the date that the record was created or as long as the information remains in our files. In addition you have the right to request an amendment to your health information. Requests to inspect, copy or amend your health related information should be provided to us in writing.

We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information.

We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files.

Information that we use or disclose based on this privacy notice 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 have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to:

Dr. Cory L. Koch
2139 E 151st St.
Olathe, Ks. 66062
(913) 768-0000
info@kochchiro.com

This notice and consent form is effective as of April 16,2003. This notice and consent, and any alterations or amendments made hereto will expire six years after the date upon which the record was created.

You have the right not to sign this notice/authorization and you also have the right to revoke certain procedures as listed above in the said notification. You have the right to revoke authorization at a later date if you wish. If you choose to revoke authorization in the future it must be done in writing.