Burkholder Chiropractic Clinic Notice of Privacy Practices
809 N. State St., Ephrata, PA 17522

Notice of Information Practices

Protecting the privacy of your personal health information (PHI) is important to us.  This notice describes how information about you may be used and disclosed and how you can get access to this information.  Please review it carefully.

Disclosure of your protected health information without authorization is strictly limited to definded situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities.  We specifically reservce the right to discuss your PHI with your spouse, parent or guardian (if a child), health insurance or other third party payor, your family doctor, other doctors or providers for coordination of care or consultation, and under subpeona.  Any other disclosures for the purposed of treatment, payment, or practice operations will be made only after obtaining your consent.  You may request restrictions on disclosures.

Disclosures of PHI are limited to the minimum necessary for the purpose of the disclosure.  This provision does not apply to the transfer of medical records for treatment.

You may inspect and receive copies of your records within 30 days of a request to do so.  There may be reasonable cost-based fee for photocopying, postage and preparation.

You may request changes to your records.  Our practice has the right to accept or deny your request.

We maintain a history of protected health information disclosures that is accessible to you.

In the future, we may contact you for appointment reminders, announcements, and to inform you about our practice and its staff.

Our practice is required to abide by this notice.  We have the right to changes this notice in the future.  Any revisions will be prominently displayed in a clearly visible location in our office.

You may file a complaint about privacy violations by contacting our office manager, Dr. Randal Burkholder at (717) 738-3474.

This notice is effective 02/14/2005.

If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201