Magnolia Wellness Center 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. We have an ethical and legal obligation to protect the privacy of your health information, and we will only use or disclose this information in limited circumstances.

This Notice of Privacy describes how we may use and disclose your Protected Health Information (PHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI. “Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services. Medical information, including your health history, is collect from you upon your initial visit and on subsequent visits, and is then stored on your medical chart and in your patient file. Each time you visit us, we make a record of your visit. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment.

In this office your medical chart is referred to as your “travel card” and it contains the most relevant information the doctor need during your visits. While you are an active practice member your travel card is stored in an open filing system that is accessible to our staff. This open filing system is off-limits to non-employees.

Any additional medical information or related documents are stored in your patient file. Active and non-active practice member files are kept in secured storage and are off-limits to non-employees.

Medical information will be used in the assessment of your case and in the need for health care or referral purposes. We will record your current healthcare information in a record so, in the future, we can see your medical history to help in diagnosing and treatment, or to determine how well you are responding to treatment. We may provide your health information to other health providers, such as referring or specialist physicians, to assist in your treatment. Should you ever be hospitalized, we may provide the hospital or its staff with the health information it requires to provide you with effective treatment.

Some of your medical information will be transferred to a computer program for the purpose of retrieval, storage, scheduling, billing and payment purpose of practice member reimbursement of services.

Magnolia Wellness Center will store the medical information contained on your travel card and in your practice member file for a period of no less than seven (7) years.

Payment: We may use and disclose your health information so that we may bill and collect payment for the services that we provided to you. For example, we may contact your health insurer to verify your eligibility for benefits, and may need to disclose to it some details of your medical condition or expected course of treatment.

We may use or disclose your information so that a bill may be sent to you, your health insurer, or a family member. For example, we can provide you with an itemized bill that you can submit to your insurance company for reimbursement, if you coverage includes chiropractic care. The information on or accompanying the bill may include information that identifies you and your diagnosis, as well as services rendered, any procedures performed, and supplies used. Also, we may provide health information to another health care provider, such as an ambulance company that transported you to our office, to assist in their billing and collection efforts.

In the event of an overdue balance, it is our policy to send a billing notice to your primary address on file. This billing notice does not contain medical information, but it will contain the dates of your recent visits and a listing of overdue charges.

Health Care Operations: We may use and disclose your health information to assists in the operation of our practice. For example, members of our staff may use information in your health record to assess the care and outcomes in your case and others like it as part of a continuous effort to improve the quality and effectiveness of the health care and services we provide. Your information may be shared between doctors, so that we can provide the best care possible to you. We may use and disclose your health information to conduct cost-management and business planning activities for our practice. We may also provide such information to other health care entities for their health care operations. For example, we may provide information to your health insurer for its quality review purposes.

Other Permitted and Required Uses and Disclosure will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Incidental Disclosure: Magnolia Wellness Center maintains an open adjusting room and an open reception area. The doctors or staff may need to discuss an aspect of your health care or health care information with you while you are in these areas, such as when scheduling appointments, collecting payments or during your adjustment. While these communications are intended to be private, please know that it may not be possible to prevent another practice member from overhearing these conversations. If you need to have completely private discussions with the doctor regarding your care, you may request a time to be scheduled for this purpose.

In addition, during your adjustment your travel card will be kept on a table for the purpose of the doctor recording notes. While not immediately viewable to other patients, your travel card does contain medical information and will be in a supervised, but open area.

As a courtesy to our practice members, it is our policy to make a reminder call to your home or work after any missed appointments. If you are not at home, or at work, 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 a request to call our office to reschedule your appointment.

As an additional courtesy, it is also our policy to call your home or work on the working day prior to any scheduled report of findings, SRI, re-evaluation appointments, or workshops. As stated above, if you are not at home or at work, 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 appointment, along with the request to call our office if you need to cancel or reschedule your appointment. These courtesy calls are made during normal business hours at the open reception area, and as such patients in the reception area may overhear these calls at that time.

Magnolia Wellness Center offers various classes or workshops. Sign-up sheets for these groups will be available to practice members at the front reception desk. Thes sign-up sheets will not contain any personal health information, but will display the topic of the class or group and the name and phone number of each person who has signed up.

During these classes or groups, patients may be asked to share about their medical or health experiences for the purposes of education while other patients are present. Participation in this type of activity during these classes or group is not mandatory. Practice members may offer personal information strictly on a voluntary basis. In addition, we may also discloses your health care information to the person or persons responsible for your health care, such as a parent, guardian, other family members, or a nurse.

On occasion it may be necessary to seek consultation regarding your condition from other health care providers associated with Magnolia Wellness Center.

Newsletters and Other Communications: We may use your personal information in order to communicate to you via newsletters, mailing, or other means regarding treatment options, health related information, wellness programs, or other community based initiative or activities in which out practice is participating.

Chiropractic Residents and Chiropractic Students: Medical residents or medical students may observe or participate in your treatment or use your health information to assist in their training. You have the right to refuse to be examined, observed, or treated by medical residents or medical students.

Treatment Options: We may use and disclose your health information in order to inform you of alternative treatments.

Health-Related Benefits and Services: We may use and disclose health information to tell you about health related benefits or services that may be of interest to you. In face-to-face communications, such as appointments with your physician, we may tell you about other products and services that may be of interest to you.

Release to Family/Friends: Our health professionals, using their professional judgement, may disclose to a family member, other relative, close personal friend or any other person you identify, your health information to the extent it is relevant to that person’s involvement in your care or payment related to your care. We will provide you with an opportunity to object to such a disclosure whenever we practicably can do so. We may disclose the health information of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law.

Personal Representative: If you have a personal representative, such as a legal guardian, we will treat that person as if that person is you with respect to disclosures of your health information. If you become deceased, we may disclose health information to an executor or administrator of your estate to the extent that person is acting as your personal representative.

Emergencies: Magnolia Wellness Center may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care in the event of an emergency or of your death. We may disclose your health information to coroners or medical examiners.

Disaster Relief: We may disclose your health information to coordinate your care or notify family and friends of you location and condition. We will provide you with an opportunity to agree or object to such a disclosure whenever we practicably can do so.

Public Health: Magnolia Wellness Center may disclose your health information to public 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.

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 and safety of a particular person or to the general public.

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

Law Enforcement: We may disclose your health information to law enforcement officials for the purposes such as identifying or locating a suspect, fugitive, material witness, or missing person, complying with a court order or subpoena, as pertinent to criminal conduct, emergency circumstances, and other law enforcement purpose.

Specialized Government Agency: We may disclose your health information to researchers when the information does not directly identify you as the source of the information or when a waiver has been issued by an institutional review board or privacy board that has reviewed the research proposal and protocols for compliance with standards to ensure the privacy of your health information.

Workers Compensation: We may disclose your health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Marketing: Magnolia Wellness Center may contact you for marketing purposes or fundraising purposes as described below. It is our practice to engage in marketing promotions and events such as Patient Appreciation Days or seasonal promotions. During these times we may send you a letter, post card, invitation, emails, newsletter or speak with you while you are at the practice. We will provide you with information about the promotion or event, the dates and times, and request your participation or request that you refer people to participate in these events.

From time to time we participate in charitable events to raise awareness, food donations, gifts, money, etc. During these times, we may send you a letter, post card, invitation, email, newsletter, speak with you while you are in the practice, or call your home to invite you to participate in the charitable activity. We will provide you with information about the promotions or event, the dates and times, and request your participation in such events. It is not our policy to disclose any personal health information about your condition for the purpose of any sponsored events.

It is our practice to include practice member testimonials as part of the Magnolia Wellness Center website, electronic newsletter, in a binder, in brochures, and in educational videos: these may be located in an open reception area for other practice member’s review and education. These stories were written with the practice member’s knowledge and shared in these ways only after the practice member grants written permission. If the practice member choose to include their name and/or photograph with their account written permission is granted.

It is not our policy to disclose any personal health information about your condition for the purpose of Magnolia Wellness Center marketing promotions and events. Under no circumstances will we sell our patients lists of your health information to a third party without your written authorization.

Change of Ownership: In the event that Magnolia Wellness Center is sold or merged with another organization, your health information/record will become the property of the new owner.

Your Health Information Rights

The following are statements of your right with respect to your protected health information.

Right to Obtain a Paper Copy of This Notice: You have the right to a paper copy of this Notice of Privacy Practices at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy.

Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. You have a right to information that is stored electronically that is not in EHR (Electronic Health Records) software, including formation stored in MS Word, Excel, PDF, plain text and other electronic formats. To inspect and copy medical information, you must submit a written request to our Privacy Officer. If you request a copy of your medical information, we may charge a reasonable fee for the costs of labor, postage, and supplies associated with your request. We may not charge you a fee if you require your medical information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit programs. If your medical information is maintained in an electronic health record, you also have the right to request that an electronic copy of your records be sent to you or to another individual or entity. We may charge you a reasonable cost based fee limited to the labor costs associated with transmitting the electronic health record. You have a right to have this information within thirty days of receipt of your request.

Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we retain the information. To request an amendment, your request must be made in writing and submitted to our privacy officer. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by or for Magnolia Wellness Center;
• Is not part of the information which you would be permitted to inspect and copy; or is accurate and complete

If we deny your request for amendment, you may submit a statement of disagreement. We may reasonably limit the length of this statement. Your letter of disagreement will be include in your medical record, but we may also include a rebuttal statement.

Right to an Accounting of Disclosures: You have the right to request an accounting of disclosures of your health information made by us. In your accounting, we are not required to list certain disclosures, including:

• Disclosures made for treatment, payment, and health care operations purposes or disclosures made incidental to treatment, payment, and health care operations, however, if the disclosures were made through an EHR, you have the right to request an account for such disclosures that were made during the previous 3 years;
• Disclosures made pursuant to your authorization;
• Disclosures made to create a limited data set;
• Disclosures made directly to you.

To request an accounting of disclosures, you must submit your request in writing to our Privacy Officer. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you would like the accounting of disclosures (for example, on paper or electronically by email). The first account disclosures you request within any 12 month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting disclosures. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time, before any costs are incurred. Under limited circumstances mandated by federal and state law, we may temporarily deny your request for an accounting of disclosures.

Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we communicate about you to someone who is involved in your care or the payment for your care. You have a right to restrict certain disclosures of Protected Health Information to a health plan where you have paid out of pocket in full for the health care item or service. As noted above, we are not required to agree to your request. If we do agree, we will comply with your request unless the restricted information is needed to provide you with emergency treatment. To request restrictions, you must make your request in writing to our Privacy Officer. In your request, you must tell us what information you want to limit, whether you want to limit our use, disclosure, or both and to whom you want the limits to apply.

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by email. To question confidential communications, you must make your request in writing to our privacy officer. We will accommodate all reasonable requests.

Right to Receive Notice of a Breach: We are required to notify you by first class mail or email (if you have indicated a preference to receive information by email), of any breaches of Unsecured Protected Health Information as soon as possible, but in any event, no later than 60 days following the discovery of the breach. “Unsecured Protected Health Information” is information that is not secured through the use of a technology or methodology identified by the Secretary of the U.S. Department of Health and Human Services to render the Protected Health Information unusable, unreadable, and undecipherable to unauthorized users.

De-identified Information: We may use your health information to create “de-identified” information or we may disclose your information to a business associate so that the business associate can create de-identify information on your behalf. When we “de-identify” health information, we removed information that identifies you as the source of the information. Health information is considered “de-identified” only if there is no reasonable basis to believe that the health information could be used to identify you.

Changes to this Notice of Privacy: We reserve the right to change our practices and to make the new provisions effective for all your health information that we maintain. Should our information practices change, a revised Notice of Privacy Practices will be available upon request. If there is a material change, a revised Notice of Privacy Practices will be distributed to the extent required by law. We will not use or disclose your health information without your authorization, except as described in our most current Notice of Privacy Practices.

Magnolia Wellness Center 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 our Privacy and Security Officer by calling the San Francisco office at (415) 931-5878.

Complaints: Complaints about your privacy rights or how Magnolia Wellness Center has handled your health information should be directed to Dr. Stephanie Bridwell DC by calling the San Francisco office at (415) 931-5878. If the Privacy & Security Officer is not available, you may make an appointment for a personal conference in person or by telephone. Preliminary complaints may be dealt with verbally on the phone, or in person, or in writing. Complaints must be submitted in writing within 180 days of when you knew or should have known that the alleged violation occurred. If you are not satisfied with the manner in which our office handles your complaint, you may submit a formal complaint to the Secretary of the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.

This notice is effective as of March 20, 2016

As required by the Privacy Regulations, I hereby acknowledge that I have received a current copy of Magnolia Wellness Center’s “NOTICE OF PRIVACY PRACTICES.”

As required by the Privacy Regulations, Magnolia Wellness Center has explained the “Notice of Privacy Practices” to my satisfaction.

As required by Privacy Regulations, I am aware that Magnolia Wellness Center has included a provision that it reserves the right to change the terms of its notices and to make the new notice's provisions effective for all protected health information that it maintains.

By signing this Agreement, you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices.