Notice of Privacy Practices

Autry Family Chiropractic

38A Fieldstone Village Drive

Rock Spring, GA 30739

(706) 952-2600

Notice of Patient Privacy Policy

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.

If you have any questions about this Notice, please contact

our Privacy Officer or any staff member in our office.

Our Privacy Officer is _Selena Autry, DC_

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 clinic. 

It also describes our policies concerning the use and disclosure

of this information for other purposes

that are permitted or required by law.  It describes your rights

to access and control your protected

health information. 

"Protected Health Information" (PHI)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 www.autryfamilychiropractic.com,

calling the office and requesting that a revised copy be sent to you

in the mail or asking for one at the time of your next

appointment.  

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 by your doctor, 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. 

Your protected health information may also be used and disclosed

to bill for your

health care and to support the operation of the practice.

Uses and Disclosures of Protected Health Information Based

Upon Your Implied Consent

Following are examples of the types of uses and disclosures of

your protected health care information we will make,

based on this implied consent.  These examples are not meant to

be exhaustive but to describe the types of uses and

disclosures that may be made by our office.

• Treatment: We will use and disclose your protected

health information to provide, coordinate,
or manage your health care and any related services. 

This includes the coordination or management

of your health care with a third party that has already

obtained your permission to have access to your

protected health information.  For example, we would

disclose your protected health information,

as necessary, to another physician who may be treating

you.  Your protected health information 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.

In addition, we may disclose your protected health information

from time-to-time to another physician or health care

provider (e.g., a specialist or laboratory) who, at the request

of your doctor, becomes involved in your care by providing

assistance with your health care diagnosis or treatment.

• Payment: Your protected health information 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 for you such as making a determination of
eligibility or coverage for insurance benefits,

reviewing services provided to you for medical necessity,
and undertaking utilization review activities. 

For example, obtaining approval for chiropractic spinal
adjustments may require that your relevant

protected health information be disclosed to the health

plan to obtain approval for those services.

• Healthcare Operations: We may use or

disclose, as needed, your protected health information to
support the business activities of this office. 

These activities may include, but are not limited to,
quality assessment activities, employee review

activities and training of chiropractic students.

For example, we may disclose your protected health

information to chiropractic interns or precepts that see

patients at our office.  In addition, we may use a

sign-in sheet at the registration desk where you will be

asked to sign your name and indicate your doctor. 

Communications between you and the doctor or his assistants

may be recorded to assist us in accurately capturing your responses;

we may also call you by name in the reception area when your

doctor is ready to see you. 

We may use or disclose your protected health information,

as necessary, to contact you to remind you of your

appointment. We  have open therapy/adjusting areas.

We will share your protected health information with

third party "business associates" that perform various activities

(e.g., billing, transcription services for the practice). 

Whenever an arrangement between our office and a business

associate involves the use or disclosure of your protected

health information, we will have a written contract with that

business associate that contains terms that will protect the

privacy of your protected health information.

We may use or disclose your protected health information,

as necessary, to provide you with information about treatment

alternatives or other health-related benefits and services

that may be of interest to you.  We may also use and disclose your

protected health information for other internal marketing

activities.  For example, your name and address may be used to

send you a newsletter about our practice and the services

we offer, we will ask for your authorization.  We may also send

you information about products or services that we believe may

be beneficial to you.  You may contact our Privacy Officer

to request that these materials not be sent to you.

Uses and Disclosures of Protected Health Information

That May Be Made Only With Your Written Authorization

Other uses and disclosures of your protected health information

will be made only with your written authorization, unless

otherwise permitted or required by law as described below.

• Disclosures of psychotherapy notes

• Uses and disclosures of Protected Health

Information for marketing purposes;

• Disclosures that constitute a sale of

Protected Health Information;

• Other uses and disclosures not described

in the Notice of Privacy Practices will be made
only with authorization from the individual.

1. Confidentiality of Reproductive Health Information:

Our practice is committed to protecting the privacy and confidentiality

of your reproductive health information.

This includes information related to fertility treatments, prenatal care,

contraception counseling, and abortion services.

We have implemented strict safeguards to ensure that your reproductive

health data is always kept secure and confidential.

 

2. Access to Reproductive Health Records:

You have the right to access and obtain copies of your

reproductive health records maintained by our practice. These records

will only be released after obtaining a specific and separate release

of reproductive rights protected information signed by the

patent, except where required by law. If you wish to review or

receive a copy of your fertility treatment history, prenatal care

notes, contraception counseling records, or abortion services

documentation, please contact our privacy officer to initiate the

special request and authorization for such.

 

3. Non-Discrimination and Respect for Reproductive Choices:

Our practice upholds a policy of non-discrimination. We respect

and support your reproductive choices, regardless of factors

such as age, gender identity, sexual orientation, marital status,

or individual preferences. Your reproductive health records will

be honored and respected by our healthcare team.

 

4. Disclosure of Reproductive Health Information:

We will only disclose your reproductive health information to

authorized individuals or entities as permitted by law and with

your explicit consent. Your reproductive health data will not be

shared with third parties without your permission. We require

a special authorization, above and beyond a simple standard release

form, to release any reproductive care documentation,

except in cases where disclosure is required by law or for purposes

of treatment, payment, or healthcare operations.

You may revoke any of these authorizations, at any time, in writing,

except to the extent that your doctor or the practice has

taken an action in reliance on the use or disclosure indicated in the

authorization.

Other Permitted and Required Uses and Disclosures That

May Be Made With Your Authorization or Opportunity to Object

In the following instance where we may use and disclose your

protected health information, you can agree or object to the use

or disclosure of all or part of your protected health information. 

If you are not present or able to agree or object to the use or

disclosure of the protected health information, then your doctor

may, using professional judgment, determine whether the

disclosure is in your best interest.  In this case, only the protected

health information that is relevant to your health care will be

disclosed.

• Others Involved in Your Healthcare: Unless you object,

we may disclose to a member of your family, a relative,

a close friend or any other person you identify, your

protected health information that directly
relates to that person's involvement in your health care. 

If you are unable to agree or object to such a
disclosure, we may disclose such information as necessary

if we determine that it is in your best interest
based on our professional judgment.  We may use or

disclose protected health information to notify or
assist in notifying a family member, personal representative

or any other person that is responsible for
your care of your location or general condition.  Finally,

we may use or disclose your protected health
information to an authorized public or private entity to

assist in disaster relief efforts and to coordinate

uses and disclosures to family or other individuals

involved in your health care.

Other Permitted and Required Uses and, Disclosures That

May Be Made Without Your Consent,

Authorization or Opportunity to Object

We may use or disclose your protected health information in the

following situations without your consent or authorization. 

These situations include:

• Required By Law: We may use or disclose your

• protected health information to the extent that the

law requires the use or disclosure.  The use or disclosure

will be made in compliance with the law and will

be limited to the relevant requirements of the law. 

You will be notified, as required by law, of any such

uses or disclosures.

• Public Health: We may disclose your protected health

information for public health activities and
purposes to a public health authority that is permitted

by law to collect or receive the information. 
The disclosure will be made for the purpose of controlling

disease, injury or disability.  We may also
disclose your protected health information, if directed

by the public health authority, to a foreign
government agency that is collaborating with the public health authority.

• Communicable Diseases: We may disclose your

• protected health information, if authorized by law,

to a person who may have been exposed to a

communicable disease or may otherwise be at risk of

contracting or spreading the disease or condition.

• Health Oversight: We may disclose protected

• health information to a health oversight agency for

activities authorized by law, such as audits, investigations,

and inspections.  Oversight agencies seeking this

information include government agencies that oversee

the health care system, government benefit

programs, other government regulatory programs and

civil rights laws.

• Abuse or Neglect: We may disclose your protected

health information to a public health authority
that is authorized by law to receive reports of child

abuse or neglect.  In addition, we may disclose your

protected health information if we believe that you have

been a victim of abuse, neglect or domestic

violence to the governmental entity or agency authorized

to receive such information.  In this case, the

disclosure will be made consistent with the requirements

of applicable federal and state laws.

• Legal Proceedings: We may disclose protected health

information in the course of any judicial or
administrative proceeding, in response to an order of a

court or administrative tribunal (to the extent
such disclosure is expressly authorized), in certain

conditions in response to a subpoena, discovery

request or other lawful process.

• Law Enforcement: We may also disclose protected

• health information, so long as applicable legal

requirements are met, for law enforcement purposes. 

These law enforcement purposes include (I) legal

process and otherwise required by law, (2) limited

information requests for identification and location

purposes, (3) pertaining to victims of a crime,

(4) suspicion that death has occurred as a result of criminal

conduct, (5) in the event that a crime occurs on the premises

of the Practice, and (6) medical emergency

(not on the Practice's premises) and it is likely that a crime has occurred.

• Workers' Compensation: We may disclose your protected

health information, as authorized, to comply
with workers' compensation laws and other similar

legally-established programs.

• Required Uses and Disclosures: Under the law, we

must make disclosures to you and when required by
the Secretary of the Department of Health and Human

Services to investigate or determine our
compliance with the requirements of Section 164.500 et. seq.

2. Your Rights

Following is a statement of your rights with respect to your

protected health information and a brief description of how you

may exercise these rights.

• You have the right to inspect and copy your

protected health information.

This means you may inspect and obtain a copy of

protected health information about you that is contained

in a designated record set for as long as we maintain the

protected health information.  A "designated record set" contains

medical and billing records and any other records that your

doctor and the Practice uses for making

decisions about you.

Under federal law, however, you may not inspect or copy the

following records; psychotherapy notes; information complied

in reasonable anticipation of, or use in, a civil, criminal, or

administrative action or proceeding, and protected health

information that is subject to law that prohibits access to

protected health information.  Depending on the circumstances,

a decision to deny access may be reviewed.  In some circumstances,

you may have a right to have this decision reviewed. 

Please contact our Privacy Officer, if you have questions about

access to your medical record.

• You have the right to request a restriction of your

protected health information.

This means you may ask us not to use or disclose any part

of your protected health information for the purposes of treatment,

payment or healthcare operations.  You have the right to

restrict certain disclosures of Protected Health

Information to a health plan when you pay out of pocket in

full for the healthcare delivered by our office. 

You may also request that any part of your protected

health information 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.  You may opt out of fundraising

communications in which our office participates.  

Your provider is not required to agree to a restriction that you

may request.  If the doctor believes it is in your best interest

to permit use and disclosure of your protected health information,

your protected health information will not be restricted. 

If your doctor does agree to the requested restriction, we may not

use or disclose your protected health information in

violation of that restriction unless it is needed to provide emergency

treatment.  With this in mind, please discuss any

restriction you wish to request with your doctor.

You may request a restriction by presenting your request, in writing

to the staff member identified as "Privacy Officer" at

the top of this form.  The Privacy Officer will provide you with

"Restriction of Consent" form.  Complete the form, sign it,

and ask that the staff provide you with a photocopy of your

request initialed by them.  This copy will serve as your receipt.

• You have the right to request to receive confidential

communications from us by alternative means
or at an alternative location.

We will accommodate reasonable requests. 

We may also condition this accommodation by asking you for

information as to how payment will be handled or specification

of an alternative address or other method of

contact.  We will not request an explanation from you as to

the basis for the request. 

Please make this request in writing.

• You may have the right to have your doctor

amend your protected health information.
This means you may request an amendment of

protected health information about you in a designated

record set 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.  Please contact our Privacy Officer if you have

questions about amending your medical record.

• You have the right to receive an accounting of

certain disclosures we have made, if any, of your

protected health information.

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, 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.  The right to receive this information

is subject to certain exceptions, restrictions and

limits.

• You have the right to be notified by our office

of any breech of privacy of your Protected Health
Information.

• Certain treatments may be performed in a

common therapy area and/ or you may find yourself
within public areas within the clinic times, but please

note private rooms are always available, upon

request, for discussing your private health information.

You have the right to obtain a paper copy of this notice from us,

upon request, even if you have agreed to accept this

notice electronically.

3. Complaints

You may complain to us, or the Secretary of Health

and Human Services, if you believe your privacy rights have

been violated by us. To file a complaint, you may go to: 

https://www.hhs.gov/hipaa/filing-a-complaint/complaint-process/index.html

Or our office can provide you with a written form in which to file your complaint. 

You may also file a complaint with us by notifying our

Privacy Officer of your complaint. 

We will not retaliate against you for filing a complaint.

Our Privacy Officer is Selena Autry, DC

you may contact our Privacy Officer, or any staff member,

including Selena Autry, DC at the following phone number

706-952-2600 or our website www.autryfamilychiropractic.com

for further information about the complaint process.

This notice was published and becomes effective on December 22, 2024.