NOTICE OF PRIVACY PRACTICES

Orris Family Chiropractic

Effective Date: November 21, 2022

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.

We understand the importance of privacy and are committed to maintaining the confidentiality of

your medical information. We make a record of the medical care we provide and may receive

such records from others. We use these records to provide or enable other health care providers

to provide quality medical care, to obtain payment for services provided to you as allowed by

your health plan and to enable us to meet our professional and legal obligations to operate this

medical practice properly. We are required by law to maintain the privacy of protected health

information, to provide individuals with notice of our legal duties and privacy practices with

respect to protected health information, and to notify affected individuals following a breach of

unsecured protected health information. This notice describes how we may use and disclose your

medical information. It also describes your rights and our legal obligations with respect to your

medical information. If you have any questions about this Notice, please contact our Privacy

Officer listed above.

A. How This Medical Practice May Use or Disclose Your Health Information

This medical practice collects health information about you and stores it in a chart and on a

Computer, and in an electronic health record/personal health record.
This is your medical

record. The medical record is the property of this medical practice, but the information in the

medical record belongs to you. The law permits us to use or disclose your health information for

the following purposes:

1. Treatment. We use medical information about you to provide your medical care. We

disclose medical information to our employees and others who are involved in providing the

care you need. For example, we may share your medical information with other physicians

or other health care providers who will provide services that we do not provide. Or we may

share this information with a pharmacist who needs it to dispense a prescription to you, or a

laboratory that performs a test. We may also disclose medical information to members of

your family or others who can help you when you are sick or injured, or after you die.

2. Payment. We use and disclose medical information about you to obtain payment for the

services we provide. For example, we give your health plan the information it requires

before it will pay us. We may also disclose information to other health care providers to

assist them in obtaining payment for services they have provided to you.

3. Health Care Operations. We may use and disclose medical information about you to operate

this medical practice. For example, we may use and disclose this information to review and

improve the quality of care we provide, or the competence and qualifications of our

professional staff. Or we may use and disclose this information to get your health plan to

authorize services or referrals. We may also use and disclose this information as necessary

for medical reviews, legal services and audits, including fraud and abuse detection and

compliance programs and business planning and management. We may also share your

medical information with our "business associates," such as our billing service, that perform

administrative services for us. We have a written contract with each of these business

associates that contains terms requiring them and their subcontractors to protect the

confidentiality and security of your protected health information. We may also share your

information with other health care providers, health care clearinghouses or health plans that

have a relationship with you, when they request this information to help them with their

quality assessment and improvement activities, their patient-safety activities, their

population-based efforts to improve health or reduce health care costs, their protocol

development, case management or care-coordination activities, their review of competence,

qualifications and performance of health care professionals, their training programs, their

accreditation, certification or licensing activities, or their health care fraud and abuse

detection and compliance efforts.

4. Appointment Reminders. We may use and disclose medical information to

contact and remind you about appointments. If you are not home, we may leave this

information on your answering machine or in a message left with the person answering the

phone.

5. Sign In Sheet. We may use and disclose medical information about you by having you sign

in when you arrive at our office. We may also call out your name when we are ready to see

you.

6. Notification and Communication With Family. We may disclose your health information to

notify or assist in notifying a family member, your personal representative or another person

responsible for your care about your location, your general condition or, unless you had

instructed us otherwise, in the event of your death. In the event of a disaster, we may

disclose information to a relief organization so that they may coordinate these notification

efforts. We may also disclose information to someone who is involved with your care or

helps pay for your care. If you are able and available to agree or object, we will give you the

opportunity to object prior to making these disclosures, although we may disclose this

information in a disaster even over your objection if we believe it is necessary to respond to

the emergency circumstances. If you are unable or unavailable to agree or object, our health

professionals will use their best judgment in communication with your family and others.

7. Marketing. Provided we do not receive any payment for making these communications, we

may contact you to give you information about products or services related to your

treatment, case management or care coordination, or to direct or recommend other

treatments, therapies, health care providers or settings of care that may be of interest to you.

We may similarly describe products or services provided by this practice and tell you which

health plans this practice participates in. We may also encourage you to maintain a healthy

lifestyle and get recommended tests, participate in a disease management program, provide

you with small gifts, tell you about government sponsored health programs or encourage you

to purchase a product or service when we see you, for which we may be paid.

We will not otherwise use or disclose your medical information for marketing

purposes or accept any payment for other marketing communications without your prior

written authorization. The authorization will disclose whether we receive any compensation

for any marketing activity you authorize, and we will stop any future marketing activity to

the extent you revoke that authorization.

8. Sale of Health Information. We will not sell your health information without your prior

written authorization. The authorization will disclose that we will receive compensation for

your health information if you authorize us to sell it, and we will stop any future sales of

your information to the extent that you revoke that authorization.

9. Required by Law. As required by law, we will use and disclose your health information, but

we will limit our use or disclosure to the relevant requirements of the law. When the law

requires us to report abuse, neglect or domestic violence, or respond to judicial or

administrative proceedings, or to law enforcement officials, we will further comply with the

requirement set forth below concerning those activities.

10. Public Health. We may, and are sometimes required by law, to disclose your health

information to public health authorities for purposes related to: preventing or controlling

disease, injury or disability; reporting child, elder or dependent adult abuse or neglect;

reporting domestic violence; reporting to the Food and Drug Administration problems with

products and reactions to medications; and reporting disease or infection exposure. When

we report suspected elder or dependent adult abuse or domestic violence, we will inform you

or your personal representative promptly unless in our best professional judgment, we

believe the notification would place you at risk of serious harm or would require informing a

personal representative we believe is responsible for the abuse or harm.

11. Health Oversight Activities. We may, and are sometimes required by law, to disclose your

health information to health oversight agencies during the course of audits, investigations,

inspections, licensure and other proceedings, subject to the limitations imposed by law.

12. Judicial and Administrative Proceedings. We may, and are sometimes required by law, to

disclose your health information in the course of any administrative or judicial proceeding to

the extent expressly authorized by a court or administrative order. We may also disclose

information about you in response to a subpoena, discovery request or other lawful process if

reasonable efforts have been made to notify you of the request and you have not objected, or

if your objections have been resolved by a court or administrative order.

13. Law Enforcement. We may, and are sometimes required by law, to disclose your health

information to a law enforcement official for purposes such as identifying or locating a

suspect, fugitive, material witness or missing person, complying with a court order, warrant,

grand jury subpoena and other law enforcement purposes.

14. Coroners. We may, and are often required by law, to disclose your health information to

coroners in connection with their investigations of deaths.

15. Organ or Tissue Donation. We may disclose your health information to organizations

involved in procuring, banking or transplanting organs and tissues.

16. Public Safety. We may, and are sometimes required by law, to disclose your health

information to appropriate persons in order to prevent or lessen a serious and imminent

threat to the health or safety of a particular person or the general public.

17. Specialized Government Functions. We may disclose your health information for military or

national security purposes or to correctional institutions or law enforcement officers that

have you in their lawful custody.

18. Workers’ Compensation. We may disclose your health information as necessary to comply

with workers’ compensation laws. For example, to the extent your care is covered by

workers' compensation, we will make periodic reports to your employer about your

condition. We are also required by law to report cases of occupational injury or

occupational illness to the employer or workers' compensation insurer.

19. Change of Ownership. In the event that this medical practice is sold or merged with another

organization, your health information/record will become the property of the new owner,

although you will maintain the right to request that copies of your health information be

transferred to another physician or medical group.

20. Breach Notification. In the case of a breach of unsecured protected health information, we

will notify you as required by law. If you have provided us with a current e-mail address, we

may use e-mail to communicate information related to the breach. In some circumstances

our business associate may provide the notification. We may also provide notification by

other methods as appropriate.

21. Research. We may disclose your health information to researchers conducting research with

respect to which your written authorization is not required as approved by an Institutional

Review Board or privacy board, in compliance with governing law.

B. When This Medical Practice May Not Use or Disclose Your Health Information

Except as described in this Notice of Privacy Practices, this medical practice will, consistent with

its legal obligations, not use or disclose health information which identifies you without your

written authorization. If you do authorize this medical practice to use or disclose your health

information for another purpose, you may revoke your authorization in writing at any time.

C. Your Health Information Rights

1. Right to Request Special Privacy Protections. You have the right to request restrictions on

certain uses and disclosures of your health information by a written request specifying what

information you want to limit, and what limitations on our use or disclosure of that

information you wish to have imposed. If you tell us not to disclose information to your

commercial health plan concerning health care items or services for which you paid for in

full out-of-pocket, we will abide by your request, unless we must disclose the information

for treatment or legal reasons. We reserve the right to accept or reject any other request, and

will notify you of our decision.

2. Right to Request Confidential Communications. You have the right to request that you

receive your health information in a specific way or at a specific location. For example, you

may ask that we send information to a particular e-mail account or to your work address.

We will comply with all reasonable requests submitted in writing which specify how or

where you wish to receive these communications.

3. Right to Inspect and Copy. You have the right to inspect and copy your health information,

with limited exceptions. To access your medical information, you must submit a written

request detailing what information you want access to, whether you want to inspect it or get

a copy of it, and if you want a copy, your preferred form and format. We will provide copies

in your requested form and format if it is readily producible, or we will provide you with an

alternative format you find acceptable, or if we can’t agree and we maintain the record in an

electronic format, your choice of a readable electronic or hardcopy format. We will also send

a copy to any other person you designate in writing. We will charge a reasonable fee which

covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the

cost of preparing an explanation or summary. We may deny your request under limited

circumstances. If we deny your request to access your child's records or the records of an

incapacitated adult you are representing because we believe allowing access would be

reasonably likely to cause substantial harm to the patient, you will have a right to appeal our

decision. If we deny your request to access your psychotherapy notes, you will have the

right to have them transferred to another mental health professional.

4. Right to Amend or Supplement. You have a right to request that we amend your health

information that you believe is incorrect or incomplete. You must make a request to amend

in writing, and include the reasons you believe the information is inaccurate or incomplete.

We are not required to change your health information, and will provide you with

information about this medical practice's denial and how you can disagree with the denial.

We may deny your request if we do not have the information, if we did not create the

information (unless the person or entity that created the information is no longer available to

make the amendment), if you would not be permitted to inspect or copy the information at

issue, or if the information is accurate and complete as is. If we deny your request, you may

submit a written statement of your disagreement with that decision, and we may, in turn,

prepare a written rebuttal. All information related to any request to amend will be maintained

and disclosed in conjunction with any subsequent disclosure of the disputed information.

5. Right to an Accounting of Disclosures. You have a right to receive an accounting of

disclosures of your health information made by this medical practice, except that this

medical practice does not have to account for the disclosures provided to you or pursuant to

your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3

(health care operations), 6 (notification and communication with family) and 18 (specialized

government functions) of Section A of this Notice of Privacy Practices or disclosures for

purposes of research or public health which exclude direct patient identifiers, or which are

incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to

a health oversight agency or law enforcement official to the extent this medical practice has

received notice from that agency or official that providing this accounting would be

reasonably likely to impede their activities.

6. Right to a Paper or Electronic Copy of this Notice. You have a right to notice of our legal

duties and privacy practices with respect to your health information, including a right to a

paper copy of this Notice of Privacy Practices, even if you have previously requested its

receipt by e-mail.

If you would like to have a more detailed explanation of these rights or 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.

D. Changes to this Notice of Privacy Practices

We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until

such amendment is made, we are required by law to comply with the terms of this Notice

currently in effect. After an amendment is made, the revised Notice of Privacy Protections will

apply to all protected health information that we maintain, regardless of when it was created or

received. We will keep a copy of the current notice posted in our reception area, and a copy will

be available at each appointment.

E. Complaints

Complaints about this Notice of Privacy Practices or how this practice handles your

health information should be directed to our Office Manager in writing via email at info@agapefamchiro.com or via mail at attn.: office manager 409 West Osage St., Pacific, MO 63069.

If you are not satisfied with the manner in which this office handles a complaint, you may submit

a formal complaint to:

OCRMail@hhs.gov

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.