As required by the Privacy Regulations created as a result of the Health Insurance Portability
and Accountability Act of 1996 (HIPAA)
This notice describes how health information about you (as a patient of this
practice) may be used and disclosed, and how you can get access to your
individually identifiable health information.
PLEASE REVIEW THIS NOTICE CAREFULLY
A. OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to maintaining the privacy of your individually identifiable health
information (IIHI). In conducting our business, we will create records regarding you and your
treatment and the services we provide for you. We are required by law to maintain the
confidentiality of health information that identifies you. We also are required by law to provide
you with this notice of our legal duties and the privacy practices that we maintain in our
practice concerning your IIHI. By federal and state law, we must follow the terms of the notice
of privacy practices that we have in effect at this time.
We realize that these laws are complicated, but we must provide you with the following
How we may us and disclose your IIHI
Your privacy rights in your IIHI
Our obligations concerning the use and disclosure of your IIHI
The terms of this notice apply to all records containing your IIHI that are created or retained
by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any
revision or amendment to this notice will be effective for all of your records that our practice
has created or maintained in the past, and for any of your records that we may create or
maintain in the future. Our practice will post a copy of our current Notice in our offices in a
visible location at all times, and you may request a copy of our most current Notice at any time.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Augustine Sports and Family Chiropractic LLC
Trisha L. Augustine, D.C.
4130 Blackhawk Road STE #112-114
Eagan, MN 55122
C. WE MAY USE AND DISCLOSURE YOUR INDIVIDUALLY IDENTIFIABLE
HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS
The following categories describe the different ways in which we may use and disclose your
1. Treatment. Our practice may use your IIHI to treat you. Any of the people who work
for our practice – including, but not limited to our doctors, or indirectly with any
provider we refer you to – may use or disclose your IIHI in order to treat you, or to
assist others in your treatment. Additionally, we may need to disclose your IIHI to
others who may assist in your care, such as your spouse, children, or parents.
2. Payment. Our practice may use and disclose your IIHI in order to bill and collect
payment for the services and items you may receive from us. For example, we may
contact your health insurer to certify that you are eligible for benefits (and for what
range of benefits), and we may provide your insurer with details regarding your
treatment and health status to determine if your insurer will cover, or pay for, your
treatment. We also may use and disclose your IIHI to obtain payment from third parties
that may be responsible for such costs, such as family members or insurance companies.
Also, we may use your IIHI to bill you directly for services and items.
3. Health Care Operations. Our practice may use and disclose your IIHI to operate our
business. As examples of the ways in which we may use and disclose your information
for our operations, our practice may use your IIHI to evaluate the quality of care you
receive from us, or to conduct cost-management and business planning activities for our
4. Appointment Reminders. Our practice may use and disclose your IIHI to contact
you or a family member who answers the phone (or to leave a recorded message) to
remind you of an upcoming appointment. Only your name, appointment date, time, and
location will be disclosed.
5. Treatment Options. Our practice may use and disclose your IIHI to inform you of
potential treatment options or alternatives.
6. Health-Related Benefits and Services. Our practice may use and disclose your
IIHI to inform you of health-related benefits or services that may be of interest to you.
7. Release of Information to Family/Friends. Our practice may release your IIHI to
a friend or family member that is involved in your care, or who assists in taking care of
you. Our practice must have a records-release form, signed by you within the last 3
months on file in order to release your IIHI in this situation. Example, a parent or
guardian may ask that a babysitter take their child to our office for care. In this example,
the babysitter may have access to this child’s medical information.
8. Disclosures Required by Law. Our practice will use and disclose your IIHI when we
are required to do so by federal, state, or local law.
D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL
The following categories describe unique scenarios in which we may use or disclose your
identifiable health information:
1. Public Health Risks. Our practice may disclose your IIHI to public health authorities that
are authorized by law to collect information for the purpose of:
Maintaining vital records, such as births and deaths
Reporting child abuse or neglect
Preventing or controlling disease, injury or disability
Notifying a person regarding potential exposure to a communicable disease
Notifying a person regarding a potential risk for spreading or contracting a disease or
Reporting reactions to drugs or problems with products or devices
Notifying individuals if a product or device they may be using has been recalled
Notifying appropriate government agency(ies) and authority(ies) regarding the potential
abuse or neglect of an adult patient (including domestic violence); however, we will only
disclose this information if the patient agrees or we are required or authorized by law to
disclose this information
Notifying your employer under limited circumstances related primarily to workplace
injury or illness or medical surveillance
2. Health Oversight Activities. Our practice may disclose your IIHI to a health oversight
agency for activities authorized by law. Oversight activities can include, for example,
investigations, inspections, audits, surveys, licensure and disciplinary actions; civil,
administrative, and criminal procedures or actions; or other activities necessary for the
government to monitor government programs, compliance with civil rights laws and the health
care system in general.
3. Lawsuits and Similar Proceedings. Our practice may use and disclose your IIHI in
response to a court or administrative order, if you are involved in a lawsuit or similar
proceeding. We also may disclose your IIHI in response to discovery request, subpoena, or
other lawful process by another party involved in the dispute, but only if we have made an
effort to inform you of the request or to obtain an order protecting the information the party
has requested. In general, we will require that the party that requests your records provide a
records-release form, signed by you within the last 3 months.
4. Law Enforcement. We may release IIHI if asked to do so by a law enforcement official:
Regarding a crime victim in certain situations, if we are unable to obtain the person’s
Concerning a death we believe has resulted from criminal conduct
Regarding criminal conduct at our offices
In response to a warrant, summons, court order, subpoena or similar legal process
To identify/locate a suspect, material witness, fugitive or missing person
In an emergency, to report a crime (including the location or victim(s) of the crime, or
the description, identify or location of the perpetrator)
5. Deceased Patients. Our practice may release IIHI to a medical examiner or coroner to
identify a deceased individual or to identify the cause of death. If necessary, we also may
release information in order for funeral directors to perform their jobs.
6. Organs and Tissue Donation. Our practice may release your IIHI to organizations that
handle organ, eye or tissue procurement or transplantation, including organ donation banks,
as necessary to facilitate organ or tissue donation and transplantation in you are an organ
7. Research. Our practice may use and disclose your IIHI for research purposes in certain
limited circumstances. We will obtain your written authorization to use your IIHI for research
purposes except when: (a) our use or disclosure was approved by an Institutional Review
Board or a Privacy Board; (b) we obtain the oral or written agreement of a research that (i) the
information being sought is necessary for the research study; (ii) the use or disclosure of your
IIHI is being used only for the research and (iii) the researcher will not remove any of your
IIHI from our practice; or (c) the IIHI sought by the research only relates to decedents and the
researcher agrees either orally or in writing that the use or disclosure is necessary for the
research, and if we request it, to provide us with proof of death prior to access to the IIHI of the
8. Serious Threats to Health or Safety. Our practice may use and disclose your IIHI when
necessary to reduce or prevent a serious threat to your health and safety or the health and
safety of another individual or the public. Under these circumstances, we will only make
disclosures to a person or organization able to help prevent the threat.
9. Military. Our practice may disclose your IIHI if you are member of the U.S. or foreign
military forces (including veterans) and if required by the appropriate authorities.
10. National Security. Our practice may disclose your IIHI to federal officials for
intelligence and national security activities authorized by law. We also may disclose your IIHI
to federal officials in order to protect the President, other officials or foreign heads of state, or
to conduct investigations.
11. Inmates. Our practice may disclose your IIHI to correctional institutions or law
enforcement officials if you are an inmate or under the custody of a law enforcement official.
Disclosure for these purposes would be necessary: (a) for the institution to provide health care
services to you, (b) for the safety and security of the institution, and/or (c) to protect your
health and safety or the health and safety of other individuals.
12. Workers’ Compensation. Our practice may release your IIHI for worker’s
compensation and similar programs.
E. YOUR RIGHTS
1. Your Right to Limit Uses or Disclosures. You have the right to request that we do not
disclose your health information to specific individuals, companies, or organizations. If you
would like to place any restrictions on the use or disclosure of your health information, please
indicate so on the Patient Reception Form (below).
2. Your Right to Request that Your Patient Record be Amended. You have the right
to request that we amend the information in your patient record. If you would like to amend
any information in your record we will provide you with a Request to Amend Protected Health
3. Your Right to Revoke Your Authorizations. You may revoke any of your
authorizations at any time; however, your revocation must be in writing. We will not be able to
honor your revocation request if we have already released your health information before we
receive your written request to revoke your authorization.
4. Your Right to Access Your Health Information. You have the right to request a copy
of your Health Information at any time; however your request must be in writing. Upon
receiving your request, copies will be made for you within 1 week (7 days). A small paper fee
may be charged if records are over twenty (20) pages in length. Copies must be picked up in
office by you or by an identified individual on your behalf (in writing). Copies will not be sent
by mail or e-mail.