Your Information. Your Rights. Our Responsibilities.

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.


Your Rights

You have the right to:


Your Choices

You have some choices in the way that we use and share information as we:


Our Uses and Disclosures

We may use and share your information as we:


Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record:

Ask us to correct your medical record:

Request confidential communications:

Ask us to limit what we use or share:

Get a list of those with whom we’ve shared information:

Get a copy of this privacy notice:

Choose someone to act for you:

File a complaint if you feel your rights are violated:


Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

In these cases we never share your information unless you give us written permission:

In the case of fundraising:


How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues:

We can share health information about you for certain situations such as:

Do research:

We can use or share your information for health research.

Comply with the law:

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests:

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director:

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests:

We can use or share health information about you:

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.


Our Responsibilities


For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.


Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.


Last Revised Date (Effective Date of this Notice):

September 28, 2016


Designated Privacy Officer:

Keith Mondschein, DC
2577 Sheridan Drive
Tonawanda, NY 14150
drkeith@optimumchirowny.com
(716) 833-1926



Notice of Privacy Practices per http://www.hhs.gov/hipaa/for-professionals/privacy/guidance/model-notices-privacy-practices/ and is intended to be compliant with all applicable laws. Any ambiguity shall be interpreted to permit compliance with the HIPAA Rules.