urgess Chiropractic, PA

LEGAL INFORMATION
Privacy Practices:
We want you to know how your Patient Health Information (PHI) is going to be used in this office
and your rights concerning those records before we get started with your care.
The patient understands and agrees to allow this chiropractic office to use their PHI for the purpose of treatment, payment, healthcare operations and coordination of care. Also including but not limited too: Health & Safety reasons, Reporting to Law Officials, Reporting abuse victims, Reporting to Workers Compensation, Court Hearings and Filings.
The patient has the right to examine and obtain a copy of his/her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.
A patients written consent needs only to be obtained one time for all subsequent care given the patient in this office.
The patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior to the written request to revoke consent and would only apply to any care given after the request has been presented.
We have taken any and all precautions that are known by this office to ensure that your records are not available to those who do not need them.
Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.
We do not sell, rent or trade personal information and will only share information as per HIPAA guidelines.
DISCLAIMER:
The information on this website is educational/informational only. It is not medical advice and should not be used as a diagnosis, treatment or healthcare guidance. Always consult with a qualified healthcare provider for any medical condition, symptom or treatment options. This website and any use of it, including contacting via phone/email/mail/fax does NOT establish a doctor-patient relationship. The doctor-patient relationship is only formed after a full evaluation and agreement from both parties for care in our office. Every patient is different and responds differently, results may vary and in healthcare there are not guarantees. If you are experiencing a medical emergency, please call 911 immediately or seek immediate medical attention from your primary care physician or the ER. Do not rely on this website or phone/email communication with our office for
urgent medical situations.
NOTICE TO PATIENTS ACCESS TO HEALTH RECORDS & CONSUMER COMPLAINT INFORMATION In accordance with Texas Health & Safety Code 181.105, patients are entitled to instruction regarding: Requesting medical records Contacting the applicable licensing authority Filing a consumer complaint 1. HOW TO REQUST YOUR MEDICAL RECORDS Step 1: Submit a written request to our office by: Email: frontdesk@burgesschiro.com Fax: (940)387-3446 Mail: Burgess Chiropractic, PA 1100 Dallas Drive, Suite 112 Denton, TX 76205 In person during normal business hours Step 2: Include the following information: Full Name Date of Birth Phone Number Date of Treatment requested Specific records requested Signature and date Step 3: Provide a Copy of a valid government- issued photos ID Step 4: Our office will process your request in accordance with applicable Texas Law and HIPAA regulations. Reasonable copying and mailing fees may apply as permitted by law. For questions regarding records request, contact our office at: Phone: 940-243-0108 2. HOW TO CONTACT THE CHIROPRACTIC LICENSING AUTHORITY Texas Chiropractors are regulated by the: Texas Board of Chiropractic Examiners Website: TBCE.com Phone: (512) 305-6700 Mailing Address: Texas Board of Chiropractic Examiners 333 Guadalupe Strett, Ste. 3-825 Austin, Texas 78701 You may contact the board regarding: Licensing questions Disciplinary matters Professional conduct concerns Filing complaint against a chiropractor 3. HOW TO FILE A CONSUMER COMPLAINT Patients may file a consumer complaint regarding protected health information, privacy rights, or health care concerns under Texas Health & Safety Code 181.103. Step 1: Visit the Texas Attorney General Consumer Protection Website ww.texasattorneygeneral.gov Step 2. Complete the online complaint form or request a paper complaint form. Step 3. Provide: Your contact information Name of the provider or facility Description of the complaint Relevant dates and supporting documents Step 4: Submit the complaint through the Attorney Generals Website or by mail. PO BOX 12548 Austin, TX 78711-2548 Attorney General Consumer Protection Division Phone: (800) 621-0508 This Notice is provided pursuant to Texas Health & Safety Code 181.103 and 181.05