Ferstl Chiropractic Clinic Privacy Policy 4

Footer Text: Lorem ipsum dolor

Copyright 2010 Ferstl Chiropractic Clinic, P.C. Web Design and Hosting by MEMNetService DIRECTORY/SIGN-IN LOG Ferstl Chiropractic Clinic, PC maintains a directory of and sign-in log for individuals seeking care and treatment in the office. Directory and sign-in log are located in a position where staff can readily see who is seeking care in the office, as well as the individual's location within Ferstl Chiropractic Clinic, PC's office suite. This information may be seen by, and is accessible to, others who are seeking care or services in Ferstl Chiropractic Clinic, PC's offices. FAMILY/FRIENDS Ferstl Chiropractic Clinic, PC may disclose to your family member, other relative, a close personal friend, or any other person identified by you, your PHI directly relevant to such person's involvement with your care or the payment for your care. Ferstl Chiropractic Clinic, PC may also use or disclose your PHI to notify or assist in the notification (including identifying or locating) a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. However, in both cases, the following conditions will apply: (a) If you are present at or prior to the use or disclosure of your PHI, Ferstl Chiropractic Clinic, PC may use or disclose your PHI if you agree, or if Ferstl Chiropractic Clinic, PC can reasonably infer from the circumstances, based on the exercise of its professional judgment, that you do not object to use or disclosure. (b) If you are not present, Ferstl Chiropractic Clinic, PC will, in the exercise of professional judgment, determine whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is directly relevant to the person's involvement with your care. AUTHORIZATION Uses and/or disclosures, other than those described above, will be made only with your written Authorization. YOUR RIGHTS 1. You have the right to: (a) Revoke any Authorization and/or Consent, in writing, at any time. To request a revocation, you must submit a written request to Ferstl Chiropractic Clinic, PC's Privacy Officer. (b) Request restrictions on certain use and/or disclosure of your PHI as provided by law. However, Ferstl Chiropractic Clinic, PC is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to Ferstl Chiropractic Clinic, PC's Privacy Officer. In your written request, you must inform Ferstl Chiropractic Clinic, PC of what information you want to limit, whether you want to limit Ferstl Chiropractic Clinic, PC's use or disclosure, or both, and to whom you want the limits to apply. If Ferstl Chiropractic Clinic, PC agrees to your request, Ferstl Chiropractic Clinic, PC will comply with your request unless the information is needed in order to provide you with emergency treatment. (c) Receive confidential communications or PHI by alternative means or at alternative locations. You must make your request in writing to Ferstl Chiropractic Clinic, PC's Privacy Officer. Ferstl Chiropractic Clinic, PC will accommodate all reasonable requests. -4-

Privacy Policy Ferstl Chiropractic Clinic, P.C. If you have any questions regarding our privacy policies, please feel free to contact us during regular business hours. Joseph F Ferstl DC FACO Director at Large, Illinois Chiropractic Society Second Vice President American College of Chiropractic Orthopedics 1557 Weatherstone Ln Elgin IL 60123 847-741-3355 847-741-3597 fax info@ferstlchiropractic.c om