BISSLAND CHIROPRACTIC
NOTICE OF PRIVACY STATEMENT

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.

Bissland Chiropractic is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Disclosure of Your Health Care Information Treatment We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. "On occasion, it may be necessary to seek consultation regarding your condition from other health care providers associated with Bissland Chiropractic." "It is our policy to provide a substitute health care provider, authorized by Bissland Chiropractic to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary health care provider's absence due to vacation, sickness, or other emergency situation." "Our treatment area at Bissland Chiropractic is an "open" treatment room. This set up allows us to closely monitor patient treatment for the entire visit. It is our policy to protect your health information by keeping discussions in this area to a minimum. Should the need arise that you need to discuss something that needs privacy, we have a private room always available to our patients for this purpose. At no time, will your records be left unattended in the treatment area. If you are uncomfortable with the "open" treatment area, we are equipped to provide your spinal adjustment in a private room. All therapy is provided in the "open" treatment room." "It is our policy that no discussion involving protected health information will be discussed in any area where it is likely to be overheard by another person." "Certain areas of the clinic will be designated SECURE AREAS. These areas will have a sign stating that they are SECURE AREAS. At no time is any unescorted person allowed in these SECURE AREAS. We ask all patients to honor this policy for patient privacy and protection."

Payment We may disclose your health information to your insurance provider for the purpose of payment or health care operations."As a courtesy to our patients, we will submit an itemized billing statement to your insurance carrier for the purpose of payment to Bissland Chiropractic for health care services rendered. If you pay for your health care services personally, we will, as a courtesy, provide an itemized billing to your insurance carrier for the purpose of reimbursement to you. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the health care services received." "If you are involved in a workers compensation accident, motor vehicle accident, or personal injury accident, we will provide an itemized billing to the insurance carrier that is handling your claim, which will contain medical information including diagnosis, date of injury or condition, and codes which describe the health care services received. Your daily visit notes are often released to a third party carrier, insurance carrier for determination of benefits, and determination of reimbursement, and will be released upon request with proper authorization. It is our policy that none of the above information will be released to a third party without proper authorization from our patients. Should we receive an invalid authorization, we will return the authorization to the sending party, and/or request that you sign a proper authorization form here in our office authorizing our release of the information." "If you are involved in a workers compensation accident, motor vehicle accident, or personal injury accident, and hire an attorney, we will release information to your attorney including the itemized billing, diagnosis, date of injury, or condition, and codes which describe the health care services rendered. Your daily visit notes are often released to a third party carrier, insurance carrier, or attorney for determination of benefits, and determination of reimbursement, and will be released upon request with proper authorization. As with any third party, we will not release your information without a proper signed authorization that is compliant with the HIPAA guidelines."

Workers' CompensationWe may disclose your health information as necessary to comply with State Workers' Compensation Laws. This disclosure may include the insurance carrier, employer, and/or the workers compensation court. We will only release the minimum necessary information to facilitate the processing of the workers compensation claim.

Emergencies We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.

Public Health As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child 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.

Judicial and Administrative Proceedings. We may disclose your health information in the course of any administrative or judicial proceeding.

Law Enforcement. We may 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 or subpoena, and other law enforcement purposes.

Deceased Persons. We may disclose your health information to coroners or medical examiners.

Organ Donation. We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.

Research. We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board. In this situation, every attempt will be made to de-identify all information released as per HIPAA guidelines.

Public Safety. It may be necessary 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 to the general public.

Specialized Government Agencies. We may disclose your health information for military, national security, prisoner and government benefits purposes.

Marketing. We may contact you for marketing purposes or fundraising purposes, as described below:"As a courtesy to our patients, at times, we may call your home on the evening prior to your scheduled appointment to remind you of your appointment time. If you are not at home, we leave a reminder message on your answering machine or with the person answering the phone. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment." "It is our practice to participate in charitable events to raise awareness, food donations, gifts, money, etc. During these times, we may send you a letter, post card, invitation or call your home to invite you to participate in the charitable activity. We will provide you with information about the type of activity, the dates and times, and request your participation in such an event. It is not our policy to disclose any personal health information about your condition for the purpose of Bissland Chiropractic sponsored fund-raising events." "throughout the year, Bissland Chiropractic will sponsor PATIENT APPRECIATION DAYS and other patient participation events. It is our policy to send out letters, cards, or call your home for the purpose of informing you of these events. We will invite you to participate in the event. We will provide you with information about the type of event, the date and times, and request your participation in this event. It is not our policy to disclose any personal health information about your condition for the purpose of Bissland Chiropractic special promotion days or events."

Change of Ownership. In the event that Bissland Chiropractic is sold or merged with another organization, your health information/record will become the property of the new owner. In this situation, your health information will be protected by the new owner or organization in compliance with HIPAA federal guidelines.


Your Health Information Rights


Ø You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that Bissland Chiropractic is not required to agree to the restriction that you requested. Ø You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request. Ø You have the right to inspect and copy your health information. Ø You have a right to request that Bissland Chiropractic amend your protected health information. Please be advised, however, that Bissland Chiropractic is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s)and information about how you can disagree with the denial. Ø You have a right to receive an accounting of disclosures of your protected health information made by Bissland Chiropractic. Ø You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.
Changes to this Notice of Privacy Practices Bissland Chiropractic reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, Bissland Chiropractic is required by law to comply with this Notice. Bissland Chiropractic is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: Dr. James S. Bissland, DC by calling this office at 918-838-4252. If Dr. James S. Bissland, DC is not available, you may make an appointment for a personal conference in person or by telephone within 5 working days.

Complaints Complaints about your Privacy rights, or how Bissland Chiropractic has handled your health information should be directed to Dr. James S. Bissland, DC by calling this office at 918-838-4252 If Dr. James S. Bissland, DC is not available, you may make an appointment for a personal conference in person or by telephone within 5 working days. If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to: DHHS, Office of Civil Rights 200 Independence Avenue, S.W. Room 509F HHH Building Washington, DC 20201 This notice is effective as of April 14, 2003 All patients are required to sign a copy of this policy. If you haven't signed a copy please make sure you do on your next visit.

7506 East 11th Street
Tulsa, Oklahoma 74112


Phone: 918-838-4252
Text Only: 918-727-0096
Fax: 918-838-4026

Office Hours:
Monday through Friday
10:00a to 1:00p
3:00p to 6:30p

info@bissland.com