Notice of Patient Privacy Policy
Irving Park Chiropractic 1923 W Irving Park Rd Chicago, IL 60613 773.880.0880
Notice of Patient Privacy Policy Patient Messaging Consent By supplying my home phone number, mobile phone number, email address, and any other personal contact information, I authorize my health care provider to use my personal information, the name of my care provider, the time and place of my scheduled appointments and other limited information, for the purpose of notifying me of a pending appointment, a missed appointment, overdue wellness exam, lab results, or other communications via an automated outreach and messaging system. I also authorize my healthcare provider to disclose to third parties who may intercept these messages (individuals you have provided with access to your digital devices or email accounts) limited protected health information (PHI) regarding my healthcare events. I consent to receiving multiple messages per day from the automated outreach and messaging system, when necessary. I can opt out of messaging at any time. Signature required Disclosure It is important that you understand the new HIPAA laws regarding your privacy here at Irving Park Chiropractic. Any and all information with regards to your account is stored in a password protected computer in our office. We do not share or distribute any personal information with any entity, except your insurance carrier and/or 3rd party insurance. All billing is done directly from our office, all inquiries should be directed to the office manager. Any further inquiries in regards to the above disclosure should be directed to the doctor in the office. CONSENT FOR TREATMENT: I voluntarily consent to the rendering of care, including treatment and performance of diagnostic procedures. I understand that I am under the care and supervision of the attending physician and it is the responsibility of the staff to carry out the instructions of such physician(s). ASSIGNMENT OF BENEFITS: I hereby assign payment directly to the physician(s) accepting this assignment of medical benefits applicable and otherwise payable to me but not to exceed the physician’s regular charges. RELEASE OF INFORMATION: The physician(s) may disclose all or part of the patient’s record to any person or corporation which is or may be liable under a contract to the physician(s) or to the patient or to a family member or employer of the patient for all part or part of the physician(s) charges, including but not limited to, insurance companies, worker’s compensation carriers, welfare funds, or the patient’s employer. Signature required Case Share Disclosure Medical Disclosure (Pursuant to HIPAA & Applicable State Laws) Case-Share is a Third-Party Personal Injury and Work Injury Case Management Company. Case-Share inputs, tracks and monitors information, activity, communication, job injuries, doctor visits, treatment, payments, and the status of records and bills requests of the client/patient case. We take trust and responsibility seriously. Data is securely stored on servers hosted with Amazon Web Services. Description of the information to be used or disclosed: Any and all documents, information and material, including, but not limited to medical, hospital, clinic, therapist, chiropractor and other medical records as well as any and all email, correspondence, file notes, reports, telephone calls or memos to all parties in this case; to include but not limited to: radiology reports, deposition transcripts, radiology reports, other diagnostic reports (MRI, MRA, CT, EEG); test reports, clinical notes, emergency room records and reports; ambulance or paramedic records; records of medical discharge summaries; doctor’s orders; nurses notes; lab tests; exam; final accountings; summaries; receivables; itemized bill; hardware application information and all other documents, reports and/or other information, etc. whether known or developed now, or to be later acquired; video, films, x-rays, records and reports of physical therapy, treatment, or rehabilitation, including, but not limited to physical and medical condition, medical treatment and medical results thereof, my and all statements or memos and charges relating to the above. Identification of the person or class authorized to make the use or disclosure of the patient health information (PHI) Name: auto populate from demographics Address: auto populate from demographics City/State/ZIP: auto populate from demographics Date of Birth: auto populate from demographics Description of the purpose of the use of disclosure: Follow up medical treatment. EXPIRATION DATE OR EVENT (Optional): Add optional field here A photocopy of this authorization shall have the same force and effect as the original document. This authorization does not authorize the individual or entities to whom this is directed to transfer or assign this authorization to a commercial copying service without the express written consent/approval of the patient and attorney. The author of this document may revoke this authorization in writing. The documents, information or materials obtained through this authorization may be re-disclosed by the recipient, and thus may no longer be protected under this privacy rule Signature required Patient-Doctor Agreement In order for the doctors of Irving Park Chiropractic to provide their patients with the best care possible, we have developed this patient-doctor agreement. Once a treatment plan is set in place, the patient is to follow instructions given by the doctors. Please ask any questions or concerns you have regarding treatment plans as soon as possible to prevent any confusion. Missed appointments are the biggest problem we face during our treatment plans. We are respectful of your time and expect the same from you. Missed appointments without 24 hours notice negatively affects our ability to see our patients in a timely manner and inconveniences other patients. The doctors of Irving Park Chiropractic, are granted permission by the signature of ‘ autopopulate full patient name’ to evaluate and treat any condition the patient presents to our office. The patient is fully responsible for follow up treatment. The doctors will not by any means be held liable for any falsifications made on behalf of the patient’s health history. The doctors will not by any means be held liable for any cause(s) of problems due to any related treatment. The doctors at this clinic are providing a path to optimal health, and need your cooperation in order to provide you with a promising future. Let us work together as a team. Irving Park Chiropractic and Max Lazarowich D.C. are independent contractors for Doctores De Accidentes. Billing for services will be provided by Doctores De Accidentes. Signature required Medical Authorization (Pursuant to HIPAA & Applicable State Laws) Description of the information to be used of disclosed. Please disclose any and all documents, information and materials, including, but not limited to medical, Hospital, clinical, therapeutic, chiropractic or physician’s notes, records and charts. Any and all medical, hospital, clinic, therapeutic, chiropractic or physician’s notes, charts and reports; tests, tests results; operative reports, progress notes, x-rays, radiology reports, enhanced x-ray films (E.M.G., C.T., E.E.G., MRI, etc..), enhanced x-ray reports; consultant’s evaluations, reports or records; admission and discharge summaries; doctor’s orders, nurses’ notes; lab tests: emergency room records and reports, ambulance/ paramedic bills, where applicable, labor and delivery records and reports, pre-natal, fetal monitor strips, anesthesia records, statements for services, and any and all other information or documents, of whatever kind of description, of and pertaining to the said individual’s past or present medical condition, care, treatment or rehabilitation. Including, but limited to physical and mental condition, examinations made and results thereof, any and all statements of services and charges relating to the above Identification of the person or class authorized to make the use or disclosure of the patient health information (PHI): Name: Prepopulate this from the demographic page Address: City/ State/ Zip: Prepopulate this from the demographic page Date of birth Prepopulate this from the demographic page The purpose of the use or disclosure is for follow up medical treatment Patient Legal Representation/ Legal Guardian Authorized Signatory A photocopy of this authorization shall have the same force and effect as the original document. This authorization does not authorize the individuals or entities to which it is directed to transfer or assign this authorization to a commercial copying service without the express written consenter fee approval of the patient and attorney. The author or this document may revoke this authorization in writing. The documents, information or materials obtained through this authorization may be re disclosed by the recipient, and thus, may no longer be protected under this privacy rule. Expiration date or event (optional): optional fillable field here Signature of the individual, or the legal representative, legal guardian or administrator authorized to act for the individual: Signature required Consent to Use PHI Acknowledgement for Consent to Use and Disclosure of Protected Health Information Use and Disclosure of your Protected Health Information Your Protected Health Information will be used by Irving Park Chiropractic or may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of this office. Notice of Privacy Practices I agree to review the Notice of Privacy Practices available here (hyperlink) or at (www.ipchiro.com/...) for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office. I have been offered a copy of the Notice of Patient Privacy Policy. Requesting a Restriction on the Use or Disclosure of Your Information You may request a restriction on the use or disclosure of your Protected Health Information. · This office may or may not agree to restrict the use or disclosure of your Protected Health Information. · If we agree to your request, the restriction will be binding with this office. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards. Notice of Treatment in Open or Common Areas Describe and Notify private areas available upon request Revocation of Consent You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected. Signature required