Notice of Privacy Practices

GENE T. ELSESSER D.C.
13424 DIX-TOLEDO ROAD, SOUTHGATE, MICHIGAN 48195

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out your treatment, collect payment for your care and manage the operations of this office.  It also describes our policies concerning the use and disclosure of this information for other purposes that are permitted or required by law.  It also describes your rights to access and control your protected health information.  "Protected health information” is information about you, including demographic information that may identify you, that relates to your past, present or future physical or mental health or condition and related health care services.

We are required by Federal law to abide by the terms of this Notice of Privacy Practices.  We may change the terms of our notice, at any time.  The new notice will be effective for all protected health information that we maintain at that time.  You may obtain revisions to our Notice of Privacy Practices by accessing our website at www.southgatechiropractic.com, or asking for one at the time of your next appointment or calling the office and requesting that a revised copy be sent to you at your expense via USPS.

1. Uses and Disclosures of Protected Health Information
By applying to be treated in our office, you are implying consent to the use and disclosure of your protected health information (PHI) by Dr. Elsesser, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you.

Treatment:  We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services.  Your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment:  Your PHI will be used, as needed, to obtain payment for your health care services.  This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend.

Healthcare Operations:  We may use or disclose your PHI, as necessary, to notify you of an appointment, missed appointment, holiday or birthday. The notice may be delivered via email, telephone, or USPS.  You have the right to decline any or all of the fore mentioned notifications.  Your request must be specific and in writing on file in our office.

Other uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law.

2. Your Rights
Following is a statement of your rights with respect to your PHI and a brief description of how you may exercise these rights.

You have the right to inspect and copy your PHI. You may inspect and obtain a copy of your PHI for as long as we maintain this information.  You may be charged a fee for the expense of copying and delivery of your request.   Under federal law, however, you may not inspect or copy information complied in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding.  You may not inspect or copy PHI that is subject to law that prohibits access to PHI.  Depending on the circumstances, a decision to deny access may be reviewable.  Please contact Dr. Elsesser if you have questions about access to your medical record.

You have the right to request a restriction of your PHI.  This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations.  You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.  Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply.  Dr. Elsesser is not required to agree to a restriction that you may request.  If Dr. Elsesser believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted.

You may have the right to have Dr. Elsesser amend your PHI.  This means you may request an amendment of the PHI about you for as long as we maintain this information.  In certain cases, we may deny your request for an amendment.  If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI.  This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices.  It excludes disclosures we may have made to you or to family members or friends involved in your care, pursuant to a duly executed authorization or for notification purposes.  You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003.  You may request a shorter timeframe.

3. Complaints
You may complain to us or to the Secretary of Health & Human Services if you believe your privacy rights have been violated by us. You may contact Dr. Elsesser, our Privacy Contact or a staff member at 734-283-8700 or at www.southgatechiropratic.com for further information about the complaint process.  We will not retaliate against you for filing a complaint.

This notice was published & becomes effective on April 23, 2003.