New patient forms
You may view, download and print our forms using the links below.
New Patient information sheet
New patient packet
Consent to Treat Minor
personal injury new patient packet (car accidents only)
Gordon D. Elder, DC, PA dba Blair Chiropractic Clinic 1802 E 50th Street Ste 112 Lubbock, TX 79404
(806) 747-2735
Notice of Privacy Practices
Your Rights & Our Responsibilities
EFFECTIVE:
June 1, 2021
This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI. “Protected Health Information” is information about you, including demographic information that may identify you and that relates to your past, present or future physical health condition and related health care services. Please review it carefully.
Your Rights
This section explains your rights and how we are required to ac- knowledge them.
Request a copy of your paper or electronic medical record
Upon request, we will supply you with a Request to Inspect or Copy Patient Information form (also referred as a Patient Records Request form). The form contains the contact information of our compliance officer, and any related fees for copying your records. NOTE: Portions of an Electronic Health Record (if applicable) may be available via an on-line portal or other healthcare exchange. This will be noted in the request form.
We will provide a copy or a summary of your health information, usually within 15 days of your request. We may charge a reasonable fee for cost of labor, postage, and supplies associated with your request (in compliance with state and federal laws regarding medical records request). We may not charge you a fee if you require your medical information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program.
Receive a paper copy of this Notice of Privacy Practices
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.
Request correction of your medical record
Click here to access the Request to Amend Patient Record form.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request; our response will be in writing within 60 days.
Request confidential or alternative communication
Request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by email.
To request alternative communications, you must make your request in writing to our privacy officer. A Request for Alternative Communications form can be accessed here.
Ask us to limit or restrict the information we share
List individuals who are involved in your care and as a result PHI can be disclosed; a PHI Use and Disclosure Authorization form can be accessed here.
Restrict payer access. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. You must make your request in writing to our privacy office; a Request to Restrict Disclosure to Health Plan form can be found here.
Receive a list of those with whom we’ve shared your information
You have the right to request an accounting of disclosures of your health information made by us. We are not required to list certain disclosures, including: disclosures made for treatment, payment, and health care operations purposes (TPO).
You must submit your request in writing. A Request for Accounting of Disclosure form can be accessed here. In turn, you will receive a Response to Request for Disclosure form. The first accounting of disclosure request within a 12 month period will be at no cost. Additional request within that time period, will result in a charge based on the reasonable costs for providing accounting of disclosures.
Right to Receive Notice of a Breach
We are required to notify you by first class mail or by email (if you have indicated a preference to receive information by email), of any breaches of unsecured Protected Health Information as soon as possible, but in any event, no later than 30 days following the discovery of the breach.
File a complaint if you believe your privacy rights have been violated
If you believe your privacy rights have been violated, you may file a complaint with our privacy officer also referred to as compliance officer; the Complaint form can be found here (form contains the name of our privacy official and his/her contact information).
All complaints must be submitted in writing and should be submitted within 180 days of when you knew or should have known that the alleged violation occurred.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/ hipaa/complaints/
We will not retaliate against you for filing a complaint.
Your Choices
This section addresses your choices regarding health information we may share.
You have the choice to tell us to:
Share information with your family and friends about your condition.
Disclose your health information when disaster relief organizations seek your health information to coordinate your care. Note: If you are unable to communicate your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest.
We will never share your information in these cases without permission:
Marketing purposes. We are required by law to receive your written authorization before we use or disclose your health information for marketing purposes. However, we may use and disclose health information to tell you about health-related benefits or services that may be of interest to you.
Sale of your information. Under no circumstances will we sell our patient lists or your health information to a third party without your written authorization.
Our Uses and Disclosures
This section lists ways in which we may use your information and disclose it.
Healthcare Treatment
Plan your care and treatment, including preauthorization and pre-certification.
Communicate with other providers such as referring physicians.
Billing and coordination of payment for services with health plan administrator.
Quality and outcome assessments for improvement of care we render.
Contracted third-party business associates for services, such as answering services, transcriptionists, record keeping, consultants, and legal counsel.
Communicate to you via newsletters, mailings, or other means regarding treatment options, health related information, disease management programs, wellness programs, or other community-based initiatives or activities in which our practice is participating.
Public Health and Safety Issues
Product recalls
Reporting suspected abuse, neglect or domestic violence ; reporting disease or other required data in compliance with state and federal laws.
Communicating with healthcare exchanges and networks according to federal and state laws with regards to Right of Access and interoperability regulations.
Compliance with the law
Department of Health and Human Services investigations for complying with federal privacy laws.
Address workers’ compensation, law enforcement, and other government requests.
Respond to lawsuits and legal actions such as a court order, subpoena, warrant, summons, or similar process if authorized under state or federal law.
If you become deceased, we may disclose health information to an executor or administrator of your estate to the extent that person is acting as your personal representative. To include communication with medical examiner and or funeral director (if applicable).
Other
Text reminders
Product offers
Medical tips and suggestions
Our Responsibilities
If you have a personal representative, such as a legal guardian, we will treat that person as if that person is you with respect to disclosures of your health information.
We are required to notify you by first class mail or by email (if you have indicated a preference to receive information by email), of any breaches of unsecured Protected Health Information as soon as possible, but in any event, no later than 30 days following the discovery of the breach.
To provide you with notice, such as this Notice of Privacy Practices and abide by the terms of our most current Notice of Privacy Practices.
Notify you if we are unable to agree to a requested restriction.
Changes to the Terms of this Notice
We reserve the right to change our practices and to make the new provisions effective for all your health information that we maintain. Should our information practices change; a revised Notice of Privacy Practices will be available upon request. We will not use or disclose your health information without your authorization, except as described in our most current Notice of Privacy Practices. If you have limited proficiency in English, you may request a Notice of Privacy Practices in Spanish
Gordon D. Elder, DC, PA dba Blair Chiropractic Clinic
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