Terms and Policies

 

Appointment and Payment Policies

The patient and any other person responsible for payment has a right to refuse to pay, cancel payment, or be reimbursed for payment for any other service, examination, or treatment within 72 hours of responding to the advertisement for the free, discounted fee, or reduced-fee service, examination, or treatment, Ramah J. Wagner, D.C. ch8955


Cancellation Policy

Appointment cancellation must be made at least 24 hours in advance or a $25 charge will be incurred.


Check-in

New patients, please arrive for your appointment at least 15 minutes early if you do not already have your intake forms printed and filled out. 

Before You Visit

Please download, print and complete your assessment form if possible.


Facilities

Use of all technical facilities must occur with a member of staff present and providing guidance.


Medical Concerns

Your satisfaction and success at Wagner Chiropractic is our priority. Please express all medical concerns on your intake forms and do not hesitate to communicate your concerns with Dr. Wagner or your technician so that we may ensure you receive the highest quality of healthcare possible.


Wagner Chiropractic Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

This Practice 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 the Practice. The creation of a record detailing the care and services you receive

helps this office to provide you with quality health care. This Notice details how your PHI may

be  used and disclosed to third parties. This Notice also details your rights regarding your PHl.

The privacy of PHI in patient files will be protected when the files are taken to and from the

Practice by placing the files in a box or brief case and kept within the custody of a doctor or

employee of the Practice authorized to remove the files from the Practice's office. It may be

 necessary to take patient files to a facility where a patient is confined or to a patient's  home

where  the patient  is to be examined or  treated.

No Consent Required

The Practice may  use and/or disclose your PHI for the  purposes of:

(a) Treatment - ln order to provide you with the health care you require, the

Practice will provide your PHI to those health care professionals, whether on the

Practice's staff or not, directly involved in your care  so that they may understand

your health condition and needs. For example, a physician treating you for a

condition or disease may need to know the results of your latest physician

examination by this office.

(b) Payment - In order to get paid for services provided to you, the Practice will

provide your PHI, directly or through a billing service, to appropriate third party

payers, pursuant to their billing and payment requirements. For example,  the

Practice may  need to provide the Medicare program with information about health

care services that you received from the Practice so that the Practice can be

properly reimbursed. The Practice may also need to tell your insurance plan

about treatment you  are going to receive so that it  can determine whether or not it

will cover the treatment expense.

(c) Health Care Operations - ln order for the Practice to operate in  accordance

with applicable law and insurance requirements and in order for the Practice to

continue to provide quality  and efficient  care, it may  be necessary for the Practice

to compile,  use and/or disclose your PHI. For example, the Practice may use your

PHI in order to evaluate the performance of the Practice's personnel in providing

care to you.

I . The Practice may use and/or disclose your PHI, without a written Consent from you, in  the

following additional  instances:

(a) De-identified Information - Information that  does not identify you and, even without

your  name, cannol  be used to identify you.

(b) Business Associate - To a business associate if the Practice 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  the

Practice 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.

(c) Personal Representative - To a person who. under applicable law,  has the authority to

 represent you in making decisions related to your health care.

(d) Emergency Situations -

(i) for the purpose of obtaining or rendering emergency treatment to you

provided that the Practice attempts to obtain your Consent as soon as

possible; or

(ii) to a public or private entity authorized by law or by its charter to  assist

in disaster relief efforts, for the purpose of coordinating your care with

such entities in  an emergency situation.

(e) Communication Barriers - lf, due to substantial communication barriers or inability to

communicate, the Practice has been unable to obtain your Consent and the  Practice

determines, in the exercise of its professional judgment, that your Consent to  receive

treatment  is clearly inferred from the circumstances.

(f) Public Health Activities - Such activities include, for example, information collected

by  a public health authority, as authorized by law, to prevent or control  disease and  that

does not identify you and,  even without your  name, cannot  be used to identify you.

(g) Abuse, Neglect or Domestic Violence - To a government authority if the Practice is

required by law to make such disclosure. If the Practice is authorized by law to  make

such a disclosure, it will do so if it believes that the disclosure is necessary to prevent

serious harm.

(h) Health Oversight Activities -  Such activities, which must  be required by law,

involve government  agencies and may include, for example, criminal

investigations, disciplinary actions, or general oversight activities relating to  the

community's health care  system.

(i) Judicial and Adminisrative Proceeding - For example, the Practice may  be required  to

disclose your PHI in  response to a court order or a lawfully issued  subpoena.

(j) Law Enforcement  Purposes - In certain  instances, your PHI may have to  be disclosed

to  a law enforcement official. For example, your PHI may be the subject of a  grand jury

subpoena. Or, the Practice may disclose your PHI if the Practice believes that your  death

was the result of criminal conduct.

(k) Coroner or Medical Examiner - The Practice may disclose your PHI to  a coroner or

medical examiner for the purpose of identifying you or determining your cause of death.

(l) Organ, Eye or Tissue Donation - If you are an organ donor, the Practice may  disclose

your PHI to the entity to whom you  have agreed to donate your  organs.

(m) Research - If the Practice is involved in research activities, your PHI may be used, 

but such use is subject to numerous governmental requirements intended to protect  the

privacy of your PHI and that does not identify you and, even without your  name, cannot

be  used to identify you.

(n) Avert a Threat to Health or Safety - The Practice 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.

(o) Workers' Compensation - If you are involved in a Workers' Compensation claim,  the

Practice may be required to disclose your PHI to an individual or entity that  is part of the

Workers' Compensation  system.

(p) Disclosure of immunizations to schools required for admission upon your informal

agreement.

Appointment Reminder

The Practice may, from time to time, contact you to provide appointment reminders or

information about treatment altematives or other health-related benefits and  services that may be

of interest to you. The following appointment reminders  are used by the Practice: a) a  postcard

mailed to you at the address provided by you; and b) telephoning your home and leaving a

message on your answering machine or with the individual answering  the phone.

Directory/Sign-In Log

The Practice maintains a directory of and sign-in log for individuals seeking care  and

treatment in the office. Directory and sign-in logs are located in a position where staff can readily

 see who is seeking care in the office, as well as the individual's location within the Practice's

office suite. This information may be  seen by, and is accessible to, others who  are seeking care

or services in the Practice's offices.

Family/Friends

The Practice 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 the Practice to the contrary.  The

Practice may also use or disclose your PHI to notify or assist in the notification (including

identifying or locating) a family member, a personal representative, or another  person

responsible for your care, of your location, general condition or death. However, in both cases,

 the following conditions will apply:

(a) If you are present at or prior to the use or disclosure of your PHI, the Practice may use

or disclose your PHI if you agree, or if the Practice can reasonably infer from  the

circumstances, based on the exercise of its professional judgment that you do not object

to the use or disclosure.

(b) If you are not present, the Practice will, in the exercise of professional judgment,

determine whether the  use or disclosure is in your best interests and, if  so, disclose only

the PHI that is directly relevant to the  person's involvement with your  care.

Authorization

Uses and/or disclosures, other than those described above, will be made only with your

written Authorization.

Your Rights

1. You  have the right to:

(a)  Revoke any Authorization and/or Consent, in writing, at any time. To request a revocation,

you must submit a written request to the  Practice's Privacy Officer.

(b)  Request restrictions on certain  use and/or disclosure of your PHI as provided by law.

However, the Practice is not obligated to  agree to any  requested restrictions. To request

restrictions, you must submit a written request to the Practice's Privacy Officer. In your written

 request, you must inform the Practice of what inforrnation you want to limit, whether you want

to limit the Practice's use or disclosure, or both,  and to whom you want the limits to apply. If  the

Practice agrees to your request, the Practice will comply with your request  unless the information

is needed in order to provide you with emergency treatment.

(c) Receive confidential communications or PHI by altemative  means or at alternative locations.

You must make your request in witing to the Practice's Privacy Officer. The Practice will

accommodate all reasonable requests.

(d) Inspect and obtain a copy your PHI  as provided by 45 CFR 164.524. To inspect and copy

your PHI, you are requested to submit a written request to the Practice's Privacy Officer.  The

Practice can charge you a fee for the cost of copying, mailing or other supplies  associated with

your request.

(e) Amend your PHI as provided by 45 CFR 164.528. To request an amendment, you must

submit a written request to the Practice's Privacy Officer. You must provide a reason that

supports your request. The Practice may deny your request if it is not in writing, if you do not

provide a  reason in support of your request, if the information to  be amended was not created by

the Practice (unless the individual or entity that created the information is no longer available), if

the information is not part of your PHI maintained by the Practice, if the information is not part

of the information you would be permitted to inspect and copy, and/or if the information is

accurate and complete. If you disagree with the Practice's denial, you will have the right to

submit a written statement of disagreement.

(f) Receive an accounting of disclosures of your PHI as provided by 45 CFR 164.528.  The

request should indicate in what form you want  the list (such as a  paper or electronic copy).

(g) Receive  a paper copy of this Privacy Notice from the Practice upon request to the  Practice's

Privacy Officer.

(h)  Receive notice of any breach of confidentiality of your PHI by the Practice.

(i) Prohibit report of any test, examination or treatment to your health plan or anyone else for

which you pay in cash or by credit  card.

(j) Complain to the Practice or to the Office of Civit Rights, U.S. Department of Health and

Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington,

D.C. 20201, (202)619-0257, email: ocrmail@hhs.gov or to the Florida Attorney General, Office

of the Attorney General, PL-01 The Capitol,  Tallahassee, FL 32399-1050, (850)414-3300 if you

believe your privacy rights have been violated. To file  a complaint with the Practice, you must

contact the Practice's Privacy Offrcer. All complaints must be in writing.

(k)  Request copies of your PHI in electronic format.

Practice's Requirements

1. The  Practice:

(a) Is required by federal law to maintain  the privacy of your PHI  and to provide you with

this Privacy Notice detailing the Practice's legal duties  and privacy practices with respect

to your PHI.

(b) Is required by State law to maintain a higher level of confidentiality with respect to

certain portions of your medical information that is provided for under federal law. In

particular, the Practice is required to comply with the following  State statutes:

Section 381.004 relating to HIV testing, Chapter 384 relating to sexually

transmitted diseases and Section 456.057 relating to patient records ownership,

control and disclosure.

(c) Is required to abide by the terms of this Privacy Notice.

(d) Reserves the right to change the terms of this Privacy Notice and to make the new

Privacy Notice provisions effective for your entire PHI that it maintains.

(e) Will distribute any revised Privacy Notice to you prior to implementation.

(f) Will not retaliate against you for filing a complaint.

Questions and Complaints

You may obtain additional information  about our privacy practices or  express concems or

complaints to the person identified below whom is the Privacy Officer and Contact person

appointed for this practice. The Privacy Officer  is Ramah J. Wagner.

To obtain more information on, or have your questions about your rights answered, you

may contact the Practice's Privacy Officer, Ramah  J. Wagner, at 352-589-5443.

You may file  a complaint with the Privacy Officer if you believe that your privacy rights

have been violated relating to release of your protected health information. You may also

submit  a complaint to the Department of Health and Human Services the  address of which will 

be provided to you by the Privacy Officer. We will not retaliate against in any way if you

file a complaint.

EFFECTIVE DATE

This Notice is in effect as of 09/01/2014.