Your PIH Personal Health Information And Privacy Disclosure









818 774-1620



April 14, 2002






The Health Insurance Portability and Accountability Act of 1996 (HIPAA) has issued new regulations for all health practitioners. The following describes how we may use and share your personal health information – PHI – beyond our treatment, documentation and billing procedures.


1. New Age Chiropractic may use your name and address to send you greeting cards or newsletters.


2. When we release your x-rays to another office or consult with another health practitioner such as a radiologist, your name and date of birth will be shared with that office or doctor.


3. Your sign in is in your private file.


4. Your insurance companies or legal representative will be given your information as needed to approve payments of your benefits or to settle a suit for payment of your treatment.


5. All staff and Business Associates of New Age Chiropractic are in signed agreement as to the protection of your private information.


6. Patients may have an authorized legal authority which may act on behalf of the patient.


7. Patients must list below ANYONE whom they permit to be in a treatment room with them (applies to family members or persons who typically accompany you).









8. Our staff may verify to a third party who names you specifically as to your presence in our office.


9. Patients may request an appointment to review their file with a staff member at any time.


10. Your personal health information will not be used for any marketing purposes.


11. Your PIH will be shared as required in judicial matters.



I have read and understood the above.



_______________________________________________ ______________________


Signed Date





This from was revised Feb 18, 2014.