Notice of Privacy Practices
At The Discover Chiropractic Center
of North Hollywood

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.

The Health Insurance Portability & Accountability Act of 1996 (“HIPPA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential.

In the course of your care as a patient at Discover Chiropractic Center, we may need to 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, an HMO, a PPO or your employer (if they are, or may be, responsible for the payment of your services).

• Your name, address, email, phone number, and your health care records may be used to contact you regarding appointment reminders or other appointment related issues, to provide information about alternatives to your present care or other health related information that may be of interest to you. Periodically, thank you letters, referral cards, newsletters, birthday cards, postcards, paper clippings or email messages may be sent.

• If you are not at home to receive an appointment reminder, a message may be left on your answering machine or with another member of the household. 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.

Under federal law, we are also permitted or required to use or disclose your health insurance without your consent or authorization in the following circumstances:

• 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 described in the examples outlined above, will only be made upon your written authorization.

We normally provide information about your health care to you in person at the time you receive Chiropractic care from us. We may also mail information to you regarding your health care, insurance forms or about the status of your account. If you would like to receive this information at an address other than your home or, if you would like the information in a different form, please advise us in writing as to your preferences.

You have the right to inspect and/or copy your health information for seven years from the date that the record was created or for 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 to protect the 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 your 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 or persons to whom we provide the information and may no longer be protected be the federal privacy rules.

If you have a complaint regarding our privacy notice and/or our privacy practices, or would like further information about our privacy policies and practices please contact:

Chris Czajka, D.C.
5953 Laurel Canyon Blvd. Suite A
North Hollywood, CA 91607
818-506-0111

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

Should you have any questions, or if you want to make an appointment, please call

Our address is 5953 Laurel Canyon Blvd., Suite A North Hollywood, CA 91607
Located on the corner of Laurel Canyon Blvd. and Oxnard Blvd.