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.

In the course of your care as a patient at Countryside Wellness LLC, we may use or disclose personal and health related information about you in the following ways:

  • Your personal health information, including your clinical records, including written reports and x-rays, may be disclosed to another healthcare provider or hospital, if it is necessary to refer you for further diagnosis, assessment or treatment.
  • Your healthcare records, as well as your billing records, may be disclosed to another party, such as an insurance carrier, and HMO, a PPO, or your employer, if they are or may be responsible for the payment of services.

Your name, address, phone number, e-mail address and your healthcare records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information. We may also use these to advise you about health related meetings, workshops, and products that may be of interest to you. 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 information without your consent or authorization in these 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.

Any use or disclosure of your protected health information, other that as outlined above, will only be made upon your written authorization. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other that 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 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 the health protected 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 our 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 to whom we provide the information and may no longer be protected by the federal privacy rules.

If you have a complaint regarding our privacy notice, our practices or any aspect of our privacy activities you should direct your complaint to:

Dr. Rebekah Mouse.

If you would like further information about our privacy policies and practices please contact:

Dr. Rebekah Mouse.