Insurance accepted:

We accept most major insurance carriers, Workman’s Compensation, Liability.

• BlueCross BlueShield of North Carolina
• Aetna
• Cigna
• United Health Care
• Medicaid
• Medicare
• MedCost Preferred

Please provide us with your current insurance card.

As a courtesy, our staff calls and verifies benefits for all of our patients. Patients understand that verifying benefits is not a guarantee of payment and it is their responsibility to confirm the accuracy of the information given to us.

If your insurance company denies payment, the balance due is your responsibility. Should there be an overpayment, we will credit your account and you may request a refund, as long as there is no balance owed.

Payment Form

We accept payments in cash, checks, debit cards or credit cards (Visa and MasterCard).

Privacy Policy

NOTICE OF PRIVACY PRACTICES

This notice describes how your medical information may be used and disclosed and how you can obtain access to this information. Please review it carefully. We reserve the right to change our practices. Should we change our practices, we will mail a revised notice to the address you have supplied. Therefore, it is important that you provide current contact information.

Understanding your Medical Health Record Information

Each time you visit a physician or other healthcare provider, the provider makes a record of your visit. Typically, this record contains your health history, current symptoms, examination and test results, diagnosis, treatment and a plan of care for you. This information, often referred to as your medical record, served as a:

Basis for planning your care.

• Means of communication among the health professionals who contribute to your care.
• Legal document describing the care you received and why you received it.

Understanding what is in your medical records and how your health information is used, helps you to:

• Ensure its accuracy.
• Understand who, what, where, when, why and how others access your information.
• Understand continuity of care needs and requirements.

Your Rights Under the Federal Privacy Standard

Although your health records are the physical property of the healthcare provider who created it, you have certain rights with regard to the information contained therein. You have the right to:

• Request restrictions on uses and disclosures of your health information for treatment, payment and healthcare functions. Healthcare functions consist of activities that are necessary to carry out the operations of the provider, such as quality assurance and peer review. The right to request restriction does not extend to uses or disclosures permitted of required 164.502(a)(2)(i)(to you), 164.510(a)(for facility use), or 164.512(not requiring a consent or an authorization). In the case of communicable diseases, you do not have the right to request restriction. Even in those cases where restriction is requested, it may not be obtained. If it is granted, however, this restriction will be adhered to until you request otherwise or we provide further notice.
• You may request communication with by alternative means, if the request is deemed reasonable; we must grant the alternate communication.
• Received and keep a copy of this notice of information practices. A signed copy will be placed in your patient file, as federal law requires that we acknowledge receipt of your copy.
• Inspect and copy your health information. However, we do not have to grant access if we feel access would cause harm.

You do not have the right to access the following:

• Psychotherapy notes in any form.
• Information compiled in reasonable anticipation of or for use in civil, criminal or administrative actions or proceedings.
• Any information that is subject to CLIA of 1988, 42U.S.C.
• Information that was obtained from a source other than a healthcare provider under the promise of confidentiality specifically if the access would reveal the information source.

Request amendment/correction of your health information. Correction of the record is not required if:

• We did not create the record.
• The records are not available to you as discussed prior.
• The record is accurate and complete.

If we deny the request for amendment, you will be notified with a full explanation. You may return the explanation with an attached written statement outlining your proposed reasons for changes.

In other situations, the provider may deny you access if this occurs, the provider must provide you with a review of the decision within 60 days. If access is granted, we will inform you what actions are necessary for you to gain access. We reserve the right to charge a reasonable fee for making copies. The potential basis for denial includes:

• When a licensed professional has determined that the access is reasonably likely to endanger the life or physical safety of the individual or another person.
• When the information makes reference to another person and it may lead to harmful behavior.
• The request is made by the individual’s personal representative and a licensed professional has determined that is likely to cause harm to the individual or another personal.

You may obtain an accounting of non-routine uses and disclosures for those other than treatment, payment and healthcare operations. If we do provide an accounting of disclosures, it wil be done within 60 days of decision. We do not have to provide an accounting for:

• Disclosures to you
• Disclosures authorized by you
• Disclosures of limited data sets
• Facility directory or to persons involved in the care or for other notification purposes
• National security or intelligence purposes
• Correctional institutions or law enforcements
• Occurrences prior to April 2003

The Federal privacy standard requires us to:

• Maintain privacy of your health information.
• Provide you with this notice as to our legal duties and privacy practices with respect to your health information.
• Abide by the terms of this notice.
• Implement a sanction policy to discipline those who breach the privacy policies.
• Lessen the effects of any breach of privacy.

Uses and Disclosures other than for Treatments, Payment or Healthcare Operation

Business Associates: We may provide services through contracts with business associates. Example: Medical transcription may be contracted and access to your information is required in order to fulfill their job.

Directory: Unless you notify us that you object, we may use your name and general condition for directory purposes.

Notification: We may use or disclose information to notify or assist in notifying a family member or person responsible for your care of your location and general condition.

Communication with Family: Unless you object, health professionals exercising their best judgment may disclose to a family member, other relative, close personal friend or any other person you identify, health information that is relevant to that individual’s care or payment related to your care.

Research: We may disclose information to researchers when an institutional review board has ensured the use of proper protocols and privacy of your health information.

Funeral Directors: We may disclose health information to funeral directors consistent with applicable laws to enable them to carry out their duties.

Marketing/Continuity of Care: We may contact you with the following opportunities: appointment reminders, information about treatment(s), alternate treatment(s), other health related benefits; birthday cards, periodic announcements and services that may be of interest to you.

Fund Raising: We may contact you as part of a fund raising effort.

Food and Drug Administration: We may disclose to the FDA health information relevant to adverse effects/events with respect to food, drugs, supplements, products or product defaults to enable recalls, repairs or replacements.

Worker’s Compensation and Insurance: We may disclose health information to the extent authorized. We may disclose health information to facilitate referrals to another healthcare provider(s) or hospital and any party potentially responsible for payment of services. This also includes insurance programs and carriers, HMO, PPO, your employer and any other organization or group (ex. North Carolina Chiropractic Association, Third Party Liability, Med pay insurances, etc.), who may require health information for, or be required to assist in obtaining disbursement and/or reimbursement for services by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs organized by law.

Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.

Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the safety of others.

Law Enforcement: We may disclose health information as required by law or in response to a valid subpoena.

Health Oversight Agencies and Public Health Authorities: If the member of our work force or a business associate believes in good faith that we have engaged in unlawful conduct or otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public, they may disclose your health information to health oversight agencies and/or public health authorities, such as the Department of Health.

The Federal Department of Health and Human Services (DHHS): Under the privacy standards, we must disclose your health information to DHHS as necessary for them to determine our compliance with those standards.

How to Get More Information or to Report a Problem: If you have questions or would like additional information, you may contact South Charlotte Chiropractic’s Office Manager.