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HIPAA Notice of Privacy Practices

Activate Performance

414 Jackson Street, Suite 207

San Francisco, Ca 94111 

 

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. 

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Chu Activate Performance Chiropractic, Inc. (“Activate Performance,” “we,” or “us”) is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about your health condition and the care and treatment you receive from Activate Performance. This Notice details how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI. 

 

YOUR RIGHTS

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. All requests related to these rights may be received via email to info+legal@activateperformance.com.

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Get an electronic or paper copy of your medical record 

  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. 

  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

  • You can ask us to correct health information about you that you think is incorrect or incomplete.

  • We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address).

  • We will say “yes” to reasonable requests.

Ask us to limit what we use or share

  • You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. 

  • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. 

  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

  • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

  • You can complain if you feel we have violated your rights by contacting us using the information on page 1.

  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

  • We will not retaliate against you for filing a complaint.

 

YOUR CHOICES

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

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In the following cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care

  • Share information in a disaster relief situation

  • Include your information in a hospital directory
    If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

 

In the following cases, we never share your information unless you give us written permission:

  • Marketing purposes

  • Sale of your information

  • Most sharing of psychotherapy notes

 

OUR USES AND DISCLOSURES

We typically use or share your health information in the following ways, which you consent to by requesting services from Activate Performance:

  • Treatment: We can use your health information and share it with other professionals who are treating you.

  • Billing and Payment: We can use and share your health information to bill and get payment from health plans or other entities.

  • Health Care Operations: We can use and share your health information to run our practice, improve your care, and contact you when necessary.

  • Business Associates: To a business associate if Activate Performance obtains satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI. A business associate is an entity that assists Activate Performance in undertaking some essential function, such as a billing company that assists the office in submitting claims for payment to insurance companies or other payers.

  • Appointment Reminders: We may disclose your health information to contact you to provide appointment reminders. If you are not at home to receive an appointment reminder, a message will be left as voicemail, or with the person who answers the call. Text messages and email may also be used to contact you regarding appointment reminders and scheduling. You have the right to refuse us authorization to provide reminders. 

 

We may also use or share your health information in the following ways, which you consent to by requesting services from Activate Performance: 

  • Personal Representation: To a person who, under applicable law, has the authority to represent you in making decisions related to your health care. 

  • Emergency Situations: (i) For the purpose or rendering emergency treatment to you provided that Activate Performance attempts to obtain your consent as soon as possible; or (ii) To a public or private entity authorized by law or its charter to assist in disaster relief efforts, for the purpose of coordinating your care with such entities in an emergency situation.

  • Communication Barriers: If, due to substantial communication barriers or inability to communicate, Activate Performance has been unable to obtain your consent and Activate Performance determines, in the exercise or its professional judgment, that your consent to receive treatment is clearly inferred from the circumstances. 

  • Help with Public Health and Safety Issues: We can share health information about you for certain situations such as: preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect, or domestic violence; relenting or reducing a serious threat to anyone’s health or safety; cooperating with health oversight and legal proceedings, including criminal investigations, disciplinary actions, or general oversight activities relating to the community’s health care system. 

  • Research: We can use or share your information for health research.

  • Legal Compliance: We will share information about you if state or federal laws require it, including with the Department of Health and Human Services, with law enforcement, and  in response to a court or administrative order, or in response to a subpoena.

  • Coroner or Medical Examiner: We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

  • Organ, Eye or Tissue Donation: If you are an organ donor, Activate Performance may disclose your PHI to the entity to whom you have agreed to donate your organs. 

  • Avert a Threat to Health or Safety: Activate Performance may disclose your PHI if it believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to an individual who is reasonably able to prevent or lessen the threat. 

  • Address workers’ compensation, law enforcement, and other government requests:  We can use or share health information about you for workers’ compensation claims, for law enforcement purposes or with a law enforcement official, with health oversight agencies for activities authorized by law, and/or special government functions such as military, national security, and presidential protective services.

  • Family/Friends: We 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 unless you direct us to the contrary. We may also use or disclose your PHI to notify or assist in the notification (including identifying or locating) of a family member, a personal representative, or another person responsible for your care, of your location, general condition, or death, subject to the following conditions. If you are present at or prior to the use or disclosure of your PHI, we may use or disclose your PHI if you agree, or if we can reasonably infer from the circumstances, based on the exercise of its professional judgment that you do not object to the use or disclosure.  If you are not present, we will, in the exercise of professional judgment, determine whether the use or disclosure is in your best interest and, if so, disclose only the PHI that is directly relevant to the person's involvement with your care. 

 

Uses and/or disclosures, other than those described above, will be made only with your written Authorization. You may revoke your authorization to us at any time, however, your revocation must be in writing. 

 

OUR RESPONSIBILITIES

We are required by law to:

  • Maintain the privacy and security of your protected health information. 

  • Notify you if a breach occurs that may have compromised the privacy or security of your information.

  • Follow the duties and privacy practices described in this notice and give you a copy of it. 

  • Not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. 

 

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

 

CHANGES OF THE TERMS OF THIS NOTICE

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

 

CONTACT

All feedback, comments, requests and other communications relating to this HIPAA Notice should be directed to info+legal@activateperformance.com.

Accessibility Statement

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