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Backbone of Healthcare

Notice of Privacy Practices

Effective September 1st, 2013


The Practice ("Practice"), in accordance with the Health Insurance Portability and Accountability Act (HIPPA) Privacy Rule, ("Privacy Rules") and applicable state law, is committed to protecting the privacy of your protected health information (PHI). PHI includes information about your health condition and the care and treatment you receive from the Practice. The Practice understands that information about your health is personal. This Notice explains how your PHI may be used and disclosed to third parties. This notice also details your rights regarding your PHI. The Practice is required by law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practices's legal duties and practices with respect to your PHI. The Practice is obligated to notify you promptly if a breach occurs that may have compromised the privacy and security of your PHI. The Practice is also required by law to abide by the terms of this Notice.


The Practice, in accordance with this Notice and without asking for your express consent or authorization, may use and disclose you PHI for the purposes of:

For Treatment: We may use you PHI to provide you with treament. We may disclose your PHI to doctors, nurses, technicians, clinicians, medical students, hospitals, and other health facilities involved in or consulting in your care. We may also disclose information about you to people outside the practice, such as other health care providers involved in providing treatment for you, and to people who may be involved in your care, such as family members, clergy or others we use to provide services that are part of of your care. If we refer you to another healthcare provider, we would as part of the referral process share PHI information about you. For example, if you were referred to a specialist, we would contact the doctor's office and provide such information about you to them so that they would be fully informed to provide services to you.

For Payment: We may use and disclose your PHI so we can be paid for the services we provide to you. For example, we may need to give your insurance company information about health care services we provide to you so your insurance company will pay us for those services or reimburse you for amounts you have not paid. We also may need to provide your insurance company or a government program, such as Medicare or Medicaid, with information about your condition and the health care you need to receive prior to approval or to determine whether your plan will cover the services.

For Health Care Operations: We may use and disclose your PHI for our own health care operations and the operations of other individuals or organizations involved with providing your care. This is necessary for us to operate and to make sure that our patients receive quality health care. For example, we may use information about you to review the services we provide and the performance of our employees caring for you.


The Practice may also use and disclose your PHI without your consent or authorization in the followoing instances:

Appointment Reminders: We may use and disclose your PHI to remind you by telephone or mail about appointments that you have with us, annual exams or to follow up on missed or cancelled appointments.

Individuals Involved in Your Care or Payment for Your Care: We may disclose to a family member, other relative, a close friend, or any other person identified by you, certain limited PHI that is directly related to that person's involvement with your care or payment for your care. We may use or disclose your PHI to notify those persons of your location or general condition. This includes in the event of your death unless you have specifically instructed us otherwise. If you are unable to specifically agree or object, we may use our best judgement when communicating with your family and others.

Disaster Relief: We also may use or disclose your PHI to an authorized public or private entity to assist with disaster relief. This will be done to coordinate information with those organizations in notifying a family member, other relative, close friend or other individual of your location and general condition.

Identified Information: The Practice may use and disclose PHI to a person who, under applicable law, has the authority to represent you in making decisions related to your health care.

Business Associate: The Practice may use and disclose PHI to one or more of its business associates if the Practice obtains satisfactory written assurances, 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 essentail function, such as a billing company that assists the office in submitting claims for payments to insurance companies.

Personal Representative: The Practice may use and disclose PHI to a person who under applicable law, has the authority to represent you in making decisions related to your health care.

Emergency Situations: The Practice may use and disclose PHI for the purposes of obtaining or rendering emergency treatments to you provided the Practice attempts to obtain your consent as soon as possible. The Practice may also use and disclose PHI to a public entitiy 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.

Public Health and Safety Activities: The Practice may disclose your PHI about you for your public health activities and purposes. This includes reporting information to a public health authority that is authorized by law to collect or receive information. These activities generally include:

*To provide or control disease, injury or disability

*To report birth or death

*To report child, elder or dependent adult abuse or neglect

*To report reactions to medications or problems with products

*To notify people or recalls of products they may be using

*To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a condition or disease.

Victims of Abuse, Neglect or Domestic Violence: We may disclose your PHI to a government authority authorized by law to receive reports of abuse, neglect or domestic violence, if we believe an adult or child is a victim of abuse, neglect or domestic violence. This will occur to the extent the discloser is (a) required by law, (b) agreed to by you, (c) authorized by law and we beleive the disclosure is necessary to prevent serious harm, or (d) if you are incapaciatated and certain other conditions are met, a law informant or other publice official represents that immediate enforcement activitiy depends on the disclosure.

Health Oversight Activities: We may disclose your PHI to a health oversight agency for activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions. These and similar types of activities are necessary for appropriate oversight agencies to monitor the nation's health care system, government benefit programs, and for the enforcement of civil rights laws.

Judicial and Administrative Proceedings: We may disclose your PHI in response to a court or administrative order. We also may disclose information about you in response to a subpoena, discovery, request or other legal process; but only if efforts have been made to tell you about the request or to obtain an order protecting the information to be disclosed

Disclosures for Law Enforcement Purposes: We may disclose your PHI to law enforcement officials for these purposes:

*As required by Law

*In response to a court, grand jury or administrative order, warrant or subpoena

*To identify or locate a suspect, fugititve, material witness or missing person

*About an actual or suspected victim of a crime, in underder certain limited cirsumstances, we are unable to obtain that person's agreement

*To alert a potential victim or victimes of intending harm ("duty to warn")

*To alert law enforcement officiails to a death if we supect the death may have resulted from ciminal conduct

*About crimes that occur at our facility

*To report a crime, a victim of a crime or a person who committed a crime in emergency circumstances

To Avert Serious Threat to Health or Safety: We will use and disclose your PHI when we have a "duty to report" under state or federal law because we believe that it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure would be to help prevent a threat.

Coroners, Medical Examiners and Funeral Directors: We may disclose your PHI to a coroner or medical examiner for purposes such as identifying a deceased person and determining cause of death. We also may disclose information to a funeral director so they can carry out their duties.

Organ, Eye or Tissue Donation: To facilitate organ, eye or tissue donation and transplantation, we may disclose your PHI to organizations that handle organ procurement, banking and transportation.

Worker's Compensation: We may disclose your PHI to the extent necessary to comply with worker's compensation and similar laws that provide benefits for work-related injuries or illness without regard to fault.

Special Government Functions: If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release information about foreign military authority, or information about you to authorized federal officials for intelligence, counter-intelligence and other security activities authorized by law.

Research: We may use and disclose your PHI for research projects that are subject to special review process. If resarchers are allowed access to information, that information that identifies who you are, we will ask your permission.
Fundraising: We may contact you with respect for fundraising campaigns. If you do not wish to be contacted for fundraising campaigns, please notify our Privacy Officer in writing.


The following uses and/or disclosures specifically require your express written permission.

Marketing Purposes: We will not use or disclose your PHI for marketing pruposes for which we have accepted payment without your express written permission. However, we may contact you with information about products, services or treamtent alternativesdirectly related to your treatment and care.

Sale of Health Information: We will not sell your PHI without your written authorization. If you do authorize such a sale, the authorization will disclose that we will receive compensation for the information that you have authorized us to sell. You have the right to revoke the authorization at any time, which will halt any further sale. Uses and/or disclosures other than those described in this Notice will be made only with your written permission. If you do authorize a use and/or disclosure, you have the right to revoke that authorization at any time by submitting a revocation in writing to our Privacy Officer. However, revocation cannot be retroactive and will only impact uses and/or disclosures after the date of revocation.


Right to Revoke Authorization: You have the right to revoke any Authorization or consent you have given to the Practice at any time. To request a revocation, you must submit a written request to the Practice's Privacy Officer.

Right to Request Restrictions: You have the right to request that we restrict the uses of disclosures of your infoamtion for treatment, payment or healthcare operations. You may also request that we limit the information we share about you with a relative or friend of yours. You also have the right to restrict disclosure of information to your commercial health insurance plan regarding services or products that you paid for in full, out-of-pocket, and we will abide by that request unless we are legally obligated to do otherwise. We are not required to agree to any other request restriction. If we agree, we will follow your request unless the information is needed to a) give you emergency treatment, b) report to the Department of Health and Human Services, or c) the disclosure is described in the "uses and Disclosrues That Are Required or Permitted by Law" section. To request a restriction, you must provide your request in writing to the Practice's Privacy Officer. You must tell us: a) what information you want to limit, b) whether you want to limit use or disclosure or both, and c) to whom you want the limits to apply. Either you or we can terminate restrictions at a later date.

Right to Receive Confidential Communications: You have the right to request that we communicate your PHI in a certain way or at a certain place. For example, you can ask that we only contact by mail or at work. If you want to request confidential communications, you must do so in writing to our Practice's Privacy Officer and explain how or where you can be contacted. You do not need to give us a reason for your request. We will accommodate all reasonable requests.

Right to Insupect and Copy: You have the right to inspect and request copies of your information. To inspect or copy your information, you may either complete an Authorization to Release/Obtain Information form or write a letter of request, stating the type of information to be released, the date(s) of service being requested, the purpose of the request, and whether you wish to review the record or recieve copies of the requested information in your preferred format. We will abide by your request in the format you have requested, if we are able to do so. If we cannot provide your records to you in the requested formart, we will attempt to provide them in an alternative format that you agree to. You may also request that your records be sent to another person that you have designated in writing. Direct the request to the Practice Privacy Officer. You may be charged a fee for the cost of copying, mailing or other expenses related with your request. We may deny your request to inspect and copy information in a few limited situations. If your request is denied, you may ask for our decision to be reviewed. The Practice will choose a licensed health care professional to review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of that review.

Right to File a Complaint: You have the right to complain to the Practice or to the United States Secreary of Health and Human Services (as provided by the Privacy Rule) if you believe your privacy rights have been violated. To file a complaint with the Practice, you must contact the Practice's Privacy Officer. To file a complaint with the United States Secretary of Health and Human Services, you may write to: Office for Civil Rights, U.S. Department of Health and Human Services, 200 Indpendence Ave. S.W., Washington, D.C. 20201. All complaints must be in writing.

To obtain more information about your privacy rights or if you have questions about your privacy rights, you may contact the Practice Privacy Officer as follows:

Dr. Chad Hackel 606 South 9th Ave Broken Bow, NE 68822 Phone number 308-872-2171

Right to Amend: If you feel that your PHI is incorrect, you have the right to asks us to amend it, for as long as the information is maintained with us. To request an amendment, you must submit your request in writing to the Practice's Privacy Officer. In addition, you must provide a reason for the requested amendment. We may deny your request for an amendment if it is not in writing or does not include a reason for wanting the amendment. We also may deny your request if the information: a) was not created by us, unless the person or entitiy that created the infoamtion is no longer available to amend the informaiton, b) is not part of the information maintained by the Practice, c) is not information that you would be permitted to inspect and copy or d) is accurate and complete. If your request is granted the Practice will make the appropriate changes and inform you and others as needed and required. If we deny your request, we will explain the denial in writing to your and explain any further steps you may wish to take.

Right to an Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of certain disclosures we have made regarding your PHI. To request and accounting of disclosres, you must write to the Practice Privacy's Officer. Your request must state a time period for the disclosures. The time period may be up to six years prior to the date which you request the list, but may not include disclosures made before April 14th, 2003. There is not a charge for the first list we provide to you in any 12 month period. For additional lists, we may charge you for the cost of providing the lists. If there will be a cost, we will notify you of the charge in advance. You may withdraw or change your request to avoid or reduce the fee. Certain types of disclosures are not included in such an accounting. These include disclosures made for treatment, payment or healthcare operations; disclosures made to your for our facility directory; disclosures made with your authorization; disclosures for National Security or Intelligence purposes or to correctional institutions or law enforcement officials in some circumstances.

Right to a Paper Copy of this Notice: You have the right to receive a paper copy of this Notice of Privacy Practices, even if you agreed to recieve this Notification electronically. You may request a paper copy of this Notice at any time.

We encourage your feedback and we will not retaliate against you in any manner for the filing of a complaint. The Practice reserves the right to change this Notice and make the revised Notice effective for all health inforamtion that we had at the time, and any information we create or receive in the future. We will distribute any revised Notice to you prior to implementation.

I acknowledge receipt of a copy fo this Notice, and my understand and agreement to its terms.

Patient _____________________________________________ Date ________________________________

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