Function Performance Sport Chiropractic
NOTICE OF PRIVACY PRACTICES
Function Performance Sport Chiropractic is required, by law, to maintain the privacy and confidentiality of your
protected health information and to provide our patients with notice of our legal duties and privacy practices with
respect to your protected health information
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Described as follows are the ways we may use and disclose health information that identifies you. Except for the following purposes, we will use and disclose health information only with your written permission.
Treatment We may use and disclose health information to other health professionals within our practice for the purpose of treatment, payment, or health care operation activities.
Payment We may use and disclose health information so that we or others may bill and receive payment from you, insurance companies, or a third party for treatment and services you received.
Health Care Operations We may use and disclose health information for health operation purposes. These uses and disclosures are necessary to make sure that all our patients receive quality care to operate and manage our office. We also may share information with our entities that have a relationship with you (your health plan) for their healthcare operation activities.
Emergencies We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care, about your medical condition or in the event of an emergency or of your death. As required by law We will disclose health information when required to do so by international, federal, state, or local
Threat to Health or Safety We will disclose health information when necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or to the general public.
Business Associates We may disclose health information to our business associates that perform functions on our behalf as is necessary for such functions or services. All business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than that as specific in our contract.
Specialized Government Agencies We may disclose your health information for military, national security, prisoner and government benefit purposes. Workers Compensation We may release health information as necessary to comply with state Workers’ Compensation Laws.
Public Health Risks As required by law, may disclose health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child and elder abuse or neglect; reporting domestic violence; reporting to the FDA about reactions to medications or problems with products; reporting disease or infection exposure.
Lawsuits and Disputes We may disclose health information in a response to an administrative or judicial proceeding. We also may disclose health information in a response to a subpoena, discovery request, or other lawful process by someone else involved in a dispute.
Law Enforcement We may release health information if asked by a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena and other law enforcement purposes.
Deceased Persons We may release health information to a coroner or medical examiner. Other Services We may use and disclose health information to contact you and remind you that you have an appointment with us or to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.
You have the right to request a restriction on certain uses and disclosures of your health information. Please be
advised that Function Performance Sport Chiropractic is not required to agree to the restriction that you requested.
You have the right to inspect and copy health information. This includes medical and billing records, other than
If you feel that health information we have is incorrect or incomplete, you may ask us to amend the information.
Please be advised that Function Performance Sport Chiropractic is not required to agree to the restriction that you
requested. You may utilize this right for as long as Function Performance Sport Chiropractic is in ownership of your
protected health information.
You have the right to request that we communicate with you about your medical matters in a certain way or at a
certain location. Your request must specify how or where you wish to be contacted. We will accommodate reasonable
You have the right to receive an accounting of disclosures of your protected health information made by Function
Performance Sport Chiropractic
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.
All requests for restrictions, inspections, amendments to your health information must be made in writing and
submitted to our Privacy Officer.
CHANGES TO THIS NOTICE
We reserve the right to change this notice and make the new notice apply to health information we already have as
well as any information we receive in the future. Until such changes are made, we are required by law to comply with
Function Performance Sport Chiropractic is required by law to maintain the privacy of your health information and to
provide you with notice of your legal duties and privacy practices regarding your health information. If you have
questions or want more information about your privacy rights, please contact us by calling 503-730-2788. If we are
unavailable, you may make an appointment for a conference in person or by telephone within 2 business days.
Complaints about your privacy rights, or how employees of Function Performance Sport Chiropractic have handled
your health information should be directed at Dr. Ben Hokenson at 503-730-2788. If he is unavailable, you may make
an appointment for a conference in person or by telephone within 2 business days. You will not be penalized for filing
If you are not satisfied with how your complaint was handled, you may submit a formal complaint with the Department
of Health and Human Services. Information about filing a formal complaint can be found at: