Who are we? Our website address is: https://thesperoclinic.com.
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This Website may collect and use the following kinds of personal information:
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In addition to the disclosures reasonably necessary for the purposes identified elsewhere above, This Website may disclose your personal information to the extent that it is required to do so by law, in connection with any legal proceedings or prospective legal proceedings, and in order to establish, exercise or defend its legal rights.
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Types of personal data collected by our website may or may not include. IP addresses, cookie identifiers or other tracking technologies such as pixels, user information including name, email, phone and end-user website activity.
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This Website will take reasonable technical and organizational precautions to prevent the loss, misuse or alteration of your personal information.
This Website will store all the personal information you provide on its servers.
Cross-border data transfers
Information that This Website collects may be stored and processed in and transferred between any of the countries in which This Website operates to enable the use of the information in accordance with this privacy policy.
In addition, personal information that you submit for publication on the website will be published on the internet and may be available around the world.
You agree to such cross-border transfers of personal information.
Updating this statement
This Website may update this privacy policy by posting a new version on this website.
You should check this page occasionally to ensure you are familiar with any changes.
Other websites
This website contains links to other websites.
This Website is not responsible for the privacy policies or practices of any third party.
General Disclaimer
Pursuant to U.S. State & Federal Laws the following is a statement of your
legal rights.
Disclaimer & Legal Rights
No Warranties
We provide no promise of results by using our services, products or website.
ALL WEB SITES, PRODUCTS AND SERVICES ARE PROVIDED, AS IS, WITHOUT WARRANTY OF ANY KIND, EITHER EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE.
OUR COMPANY DOES NOT WARRANT, GUARANTEE, OR MAKE ANY REPRESENTATIONS REGARDING THE USE, OR THE RESULTS OF THE USE, OF THE WEB SITES, PRODUCTS, SERVICES OR WRITTEN MATERIALS IN THE TERMS OF CORRECTNESS, ACCURACY, RELIABILITY, CURRENTNESS OR OTHERWISE. THE ENTIRE RISK AS TO THE RESULTS AND PERFORMANCE OF THE WEB SITES, PRODUCTS AND SERVICES ARE ASSUMED BY YOU. IF THE WEB SITES, PRODUCTS, SERVICES OR WRITTEN MATERIALS ARE DEFECTIVE, YOU, AND NOT OUR COMPANY, ASSUME THE ENTIRE COST OF ALL NECESSARY SERVICING,REPAIR OR CORRECTION.
THIS IS THE ONLY WARRANT OF ANY KIND, EITHER EXPRESS OR IMPLIED, THAT IS MADE BY OUR COMPANY. NO ORAL OR WRITTEN INFORMATION OR ADVICE GIVEN BY OUR COMPANY SHALL CREATE A WARRANTY OR IN ANY WAY INCREASE THE SCOPE OF THIS WARRANTY, AND YOU MAY NOT RELY ON SUCH INFORMATION OR ADVICE TO DO SO.
Limitation & Exclusion Of Liability
These warranties exclude all incidental or consequential damages. Our company, and its suppliers, will not be liable for any damages whatsoever, including without limitation, damages for loss of business profits, business interruption, loss of business information, or other pecuniary loss. Some states do not allow the exclusion or limitation of liability, so the above limitations may not apply to you.
Legal Forum, Choice Of Laws & Official Language
This offering is a contract between you the buyer and our business, the seller. The seller is located in Fayetteville, Arkansas, U.S.A. and by doing business with us you agree that this offering is made from Fayetteville, Arkansas, U.S.A. and shall be governed by the laws of the State of Arkansas, and the U.S.A. By electing to participate in this offer, you are entering into a contract.
This Agreement shall be governed by and construed in accordance with the laws of the State of Arkansas, without regard to its conflict of laws rules.
Any legal action arising out of this Agreement shall be litigated and enforced under the laws of the State of Arkansas. In addition, you agree to submit to the jurisdiction of the courts of the State of Arkansas, and that any legal action pursued by you shall be within the exclusive jurisdiction of the courts of Arkansas in the State of Arkansas, USA.
The terms constituting this offering are set forth in writing on this Website. You hereby agree to submit to the jurisdiction of the State and Federal Courts located in Fayetteville, Arkansas, U.S.A. to resolve any disputes or litigation hereunder. Whether or not you choose to print this offering, containing the terms and conditions as described herein, you agree that this contract constitutes a writing.
This agreement is being written in English, which is to be the official language of the contracts text and interpretation. If you do not agree with the above terms and conditions, you have the option to not participate in this offer.
Copyrights
This Web site and information contains copyrighted material, trademarks, and other proprietary information. You may not modify, publish, transmit, participate in the transfer or sale of, create derivative works of, on in any way exploit, in whole or in part, any Proprietary or other Material.
License
All images, text, contents, products and scripts are licensed and never sold, unless otherwise stated. Reproduction is prohibited. You may not use, copy, emulate, clone, rent, lease, sell, modify, decompile, disassemble, otherwise reverse engineer, or transfer the licensed program or product, or any subset of the licensed program or product, except as provided for in this agreement or expressly in writing. Any such unauthorized use shall result in immediate and automatic termination of this license and may result in criminal and/or civil prosecution.
Our company reserves all rights not expressly granted here.
Web Site Terms and Conditions of Use
Terms
By accessing this web site, you are agreeing to be bound by these web site Terms and Conditions of Use, all applicable laws and regulations, and agree that you are responsible for compliance with any applicable local laws. If you do not agree with any of these terms, you are prohibited from using or accessing this site. The materials contained in this web site are protected by applicable copyright and trade mark law.
In no event shall This Website or its suppliers be liable for any damages (including, without limitation, damages for loss of data or profit, or due to business interruption,) arising out of the use or inability to use the materials on This Website’s Internet site, even if This Website or a This Website authorized representative has been notified orally or in writing of the possibility of such damage. Because some jurisdictions do not allow limitations on implied warranties, or limitations of liability for consequential or incidental damages, these limitations may not apply to you.
Revisions and Errata
The materials appearing on This Website could include technical, typographical, or photographic errors. This Website does not warrant that any of the materials on its web site are accurate, complete, or current. This Website may make changes to the materials contained on its web site at any time without notice. This Website does not, however, make any commitment to update the materials.
Links. This Website has not reviewed all of the sites linked to its Internet web site and is not responsible for the contents of any such linked site. The inclusion of any link does not imply endorsement by This Website of the site. Use of any such linked web site is at the user’s own risk.
Site Terms of Use Modifications. This Website may revise these terms of use for its web site at any time without notice. By using this web site you are agreeing to be bound by the then current version of these Terms and Conditions of Use.
General Terms and Conditions applicable to Use of a Web Site apply.
Health Notice
We do not treat or cure disease
I hereby grant permission to The Spero Clinic, Integrated Health & Wellness Center (IH&WC) and its assigns and licensees to take photographs or videos of me, and to make recordings of my voice. I give the The Spero Clinic and TH&WC permission to use these images, videos, and recording, as well as my likeness, name and voice, as follows:
Acknowledgement for Consent to Use and Disclosure of Protected Health Information
Use and Disclosure of your Protected Health Information
Your Protected Health Information will be used by The Spero Clinic Integrated Health & Wellness Center (IH&WC) or may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the offices.
Notice of Privacy Practices
You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by our offices. I have received a copy of the Notice of Patient Privacy Policy.
Requesting a Restriction on the Use or Disclosure of Your Information
Notice of Treatment in Open or Common Areas
Describe and Notify private areas available upon request.
Revocation of Consent
You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.
You give permission to use and disclose your health information.
You agree with the following statements and agree to follow the requested procedures and policies governing your appointments and treatments at The Spero Clinic Integrated Health & Wellness Center (IH&WC). The Spero Clinic Integrated Health & Wellness Center (IH&WC) is committed to providing you with the best possible care and clinical outcome.
The staff at The Spero Clinic Integrated Health & Wellness Center (IH&WC)’s sole purpose is to remove interferences to the Central Nervous System. We do not claim to treat any specific condition, symptom, disease or syndrome.
You understand that while at The Spero Clinic Integrated Health & Wellness Center (IH&WC), you may receive care that is above industry standards in both frequency and cost, due to time constraints and the severity of your nerve interference.
The fees that you pay have been explained to you. You understand that you are paying for the staff’s expertise and for the time spent in treating me. The staff at The Spero Clinic Integrated Health & Wellness Center (IH&WC) does not guarantee any specific outcome and will not offer a refund based on treatment outcome under any circumstances.
If you choose to rent a Personal Recovery System (PRS) Unit, or a portable Frequency Specific Microcurrent unit, there will be a daily $37.50 fee. There is also a permanent $0.45 per minute charge while using the ARP Wave RX Unit. You understand these fees are not includes in you financial plan. Should you choose to purchase my own unit(s) the rental fees will no longer apply to you.
You understand that the focus is to ensure optimum environment for you to be successful in your journey to better health, The Spero Clinic Integrated Health & Wellness Center (IH&WC) uses a wide range of protocols including social behavior, dietary habits, honoring the schedule recommended to you, as well as keeping healthy boundaries with other patients and staff of the center.
You will maintain and be punctual for all your appointments and prescribed treatments without interrupting your scheduled care. Exceptions are made on a case-by-case basis with prior approval from Dr. van der Merwe. You also understand that any interruptions to your care can affect your progress. You the doctors and staff of The Spero Clinic Integrated Health & Wellness Center (IH&WC) blameless for any consequence due to interruptions in your plan.
You understand that if you are over 15 minutes late for your scheduled appointments, you will be charged in full for the appointment, and if you are 30 minutes late you will forfeit your appointment and need to reschedule for a later time. The Spero Clinic Integrated Health & Wellness Center (IH&WC) reserves the right to make exceptions upon one-hour prior notification.
You are responsible for making/maintaining your appointment times, and that they are set up on a first come basis, and at the discretion of the scheduler. The Spero Clinic Integrated Health & Wellness Center (IH&WC) will do their best to accommodate their patients need within their hours of operation.
You understand that practicing unhealthy habits (including but not limited to smoking, ingesting artificial sweeteners like aspartame often found in chewing gum, carbonated beverages and/or eating health foods) may alter the outcome of your treatments. This may cause your treatments to be more unpleasant and/or less effective.
You will participate in your prescribed treatments taking all recommended supplements while under care of The Spero Clinic Integrated Health & Wellness Center (IH&WC). Before you start taking recommended supplements from The Spero Clinic Integrated Health & Wellness Center (IH&WC), you will bring in all outside supplements for testing in combination with the new supplements from The Spero Clinic Integrated Health & Wellness Center (IH&WC). If you are taking prescribed, medications or other supplements that may interact with any supplements recommended by The Spero Clinic Integrated Health & Wellness Center (IH&WC)’s Doctors and/or staff members, you will address this with your physician.
You will do your utmost to maintain a positive attitude conducive to a beneficial outcome to your treatment and others around you.
You understand that a positive outcome is not guaranteed. Dr. van der Merwe and/or staff do not guarantee any particular outcome to any treatment. You understand that they will provide premium care and that healing happens from the inside out and not the outside in. Every individual is different and may respond differently even to identical care protocols.
You understand that the following provided by The Spero Clinic Integrated Health & Wellness Center (IH&WC) are all FDA approved:
In order to undergo any electronic modalities, you certify that you do not have a pacemaker/ICD (implanted cardiac device_, you are not pregnant, and you have not had blood clots in the past 12 months.
You understand that CRPS/RSD is specifically a progressive syndrome that may advance in an unpredictable manner. This may occur even while under the care of The Spero Clinic Integrated Health & Wellness Center (IH&WC). While Dr. van der Merwe and their staff’s treatments are considered non-invasive, you understand that any change to the nervous system may exacerbate your pain. You accept the risk and wish to continue with your treatment. You understand that the staff at The Spero Clinic Integrated Health & Wellness Center (IH&WC), is treating your nervous system only, not a specific condition.
You will not behave in a disruptive manner that may interfere with the clinic or with another patient’s care. You will not dispense any medications, prescribed or over-the-counter, to other patients while under the care of The Spero Clinic Integrated Health & Wellness Center (IH&WC), it’s Doctors and its staff. This includes legal and illegal substances.
You agree to follow all guidelines and be prepared for your treatments that require the intake of water and/or protein. 64oz of water are required per day to maintain proper hydration level to receive the best treatments possible. 32oz prior to treatment and 32oz after is necessary. Also, good sources and sufficient amounts of protein are required before and after treatments. If patient experiences detox effects such as a headache (or increase in one) or cold/flu like symptoms, please contact The Spero Clinic Integrated Health & Wellness Center (IH&WC) so we can assist you in reducing your symptoms.
You understand clearly that Technician’s phone numbers are to be contacted for medical reasons during the business hours primarily. If you have been instructed or there is immediate need you can text/call them after hours with understanding that your return text/call may take longer than usual due to the technician’s family needs or being out of phone range. You will receive a reply when they are able. You will keep texts/calls respectful, brief, and professional.
You will not communicate with the staff on any social media platform. (i.e.: Facebook, Instagram, Snapchat, etc. …)
You will not provide transportation to any other patient while under Dr. van der Merwe or their staff’s care. You also will not request or expect to be provided transportation for yourself or others while under Dr. van der Merwe or their staff’s care.
You understand that breaking this contract may result in termination of your care. At that time, a refund will be provided for any unused portion of your prepaid care plan. You understand that if you are a weekly paying patient, you will need to settle any outstanding balances before you are release from care.
If you terminate your care, any unused portion of your prepaid care plan will be refunded (prorated) to you.
Under any circumstances if you are in the building before/after hours or during lunch, you will not unlock the doors for anyone, for any reason due to HIPPA Compliance and security reasons. You will not ask anyone to open the door for you.
You will not bring any pets into the building unless they are certified service animals.
You understand that any activities you choose to participate in outside the office, including drug use, alcohol consumption, or any other activity that could potentially risk your own health and wellbeing are your choice alone. You understand that these activities may potentially negatively affect your health and/or endanger your life. You will not hold The Spero Clinic Integrated Health & Wellness Center (IH&WC) responsible for any negative effects nor consequences resulting from these choices.
Except as otherwise provided in this agreement, you agree to pay all charges related to your care or treatment in full without offset or deduction within thirty (30) days of the date of the invoice. If I should object to any portion of any invoice, you will deliver written notice to the payment address listed in the invoice within thirty (30) days of the date of the invoice, which notice will include a reasonably detailed description of each objectionable portion and the basis for each objection. All portions of any invoice for which you fail to so deliver such timely written notice shall be deemed accepted and all rights to object such portions shall be deemed forever waived. No term of this agreement may be modified, amended, or waived except by a written agreement signed by the party to be charged thereby and approved in advance by us. Each term of this agreement is severable from all other terms. Time is of the essence. This agreement shall be subject to and governed by the laws of the State of Arkansas. To the extent that there is an irreconcilable conflict between the terms of this agreement and any document executed or delivered in connection herewith, the terms of this agreement shall prevail. This agreement contains the entire agreement of the parties with respect to your care or treatment, and supersedes all prior agreements, contracts, and understandings of any kind with respect to your care or treatment, either oral or written. For purposes of this agreement, the terms “I”, “You” and “My” shall mean any of the undersigned, whether the undersigned is the patient or a guarantor of the obligations of the patient under this agreement, and the terms “we”, “us” and “our” shall mean The Spero Clinic Integrated Health & Wellness Center, LLC, and any other person or entity whom we designate to render services in connection with such care or treatment.
We are so excited to work with you. Thank you for your trust in choosing us.
You, the undersigned, hereby acknowledge that you have read, understood, and consent to all the terms of this agreement and that, if you are not the patient, hereby agree to be jointly and severally liable for, and absolutely, unconditionally, and irrevocably, guarantee the prompt and complete payment and performance of all the obligations of such patient under the terms of this agreement.
You accept financial responsibility.
This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.
If you have any questions about this Notice please contact our Privacy Officer or any staff member in our office.
Our Privacy Officer is Hannelie van der Merwe.
This notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, collect payment for your care and manage the operations of this clinic. It also describes our policies concerning the use and disclosure of this information for other purposes that are permitted or required by law. It describes your right to access and control your protected health information. “Protected Health Information” (PHI) is information about you, including demographic information that may identify you, that relates to your past, present, or future physical or mental health or condition and related health care services.
We are required by federal law to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. You may obtain revisions to our Notice of Privacy Practices by calling the office and requesting that a revised copy be send to you in the mail or asking for one at the time of your next appointment.
A. Uses and Disclosures of Protected Health Information
By applying to be treated in our office, you are implying consent to the use and disclosure of your protected health information by your doctor, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to bill for your health care and to support the operation of the practice.
Uses and Disclosures of Protected Health Information Based Upon Your Implied Consent
Follow are examples of the types of uses and disclosures of your protected health care information we will make, based on this implied consent. These examples are not meant to be exhaustive but to describe the types of uses and disclosures that may be made by our office.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to another physician who may be treating you. Your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your doctor, becomes involved in your care by providing assistance with your health care diagnosis or treatment.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may included certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to your for medical necessity, and undertaking utilization review activies. For example, obtaining approval for chiropractic spinal adjustments may require that your relevant protected health information be disclosed to the health plan to obtain approval for those services.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of this office. These activities may include, but are not limited to, quality assessment activities, employee review activities and training of chiropractic students.
For example, we may disclose your protected health information to chiropractic interns or precepts that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your doctor. Communications between you and the doctor or his assistants may be recorded to assist us in accurately capturing your responses; we may also call you by name in the reception area when your doctor is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We “Do – Do Not” have open therapy / adjusting areas.
We will share your protected health information with third party “business associates” that perform various activities (e.g.; billing, transcription services for the practice). Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract with that business associate that contains terms that will protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and service that may be of interest to you. We may also use and disclose your protected health information for other internal marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer, we will ask for your authorization. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Officer to request that these materials not be sent to you.
Uses and Disclosures of Protected Health Information That May Be Only With Your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below.
You may revoke any of these authorizations, at any time, in writing, except to the extent that your doctor or the practices has been taken an action in reliance on the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosures That May Be Made With Your Authorization or Opportunity to Object
In the following instance where we may use and disclose your protected health information, you have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your doctor may, using professional judgement, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
Others Involved In Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interested based on professional judgement. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location or general condition. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your heath care.
Other Permitted and Required Uses and, Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object
We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:
Required By Law: We may use or disclose your protected health information to the extent that the law requires the use or disclosure. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise by at risk of contracting or spreading the disease or condition.
Health Oversight: We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the government entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Legal Proceedings: We may disclose your protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosures is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may disclose your protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal process and otherwise required by law, (2) limited information requests for identification and other location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the Practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.
Workers’ Compensation: We may disclose your protected health information, as authorized, to comply with workers’ compensation laws and other similar legally-established programs.
Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
B. Your Rights
The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained and designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your doctor and the Practice uses for making decisions about you.
Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information complied in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewed. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer, if you have questions about access to your medical records.
You have the right to request a restriction of your protected health information.
This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You have the right to restrict certain disclosures of protected health information to a health plan when you pay out of pocket in full for the healthcare delivered by our office. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply. You may opt out of fundraising communications in which our office participates.
Your provider is not required to agree to a restriction that you request. If the doctor believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your doctors does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. Which this in mind, please discuss and restriction you wish to request with your doctor.
You may request a restriction by presenting your request, in writing to the staff member identified as “privacy Officer” at the top of this form. The Privacy Officer will provide you with “restriction of Consent” form. Complete the form, sign it, and ask that the staff provide you with a photocopy of your request initialed by them. This copy will serve as your receipt
You have the right to request to receive confidential communications from us by alternative means or at an alternative location.
We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to basis for the request. Please make this request in writing.
You may have the right to have your doctor amend your protected health information.
This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.
You may have the right to receive an accounting of certain disclosure we have made, if any, of your protected health information.
This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, pursuant to a duly executed authorization or for notification purposes. You have the right to receive specific information regarding these disclosure that occurred after April 14, 2003. The right receive this information is subject to certain exceptions, restrictions and limits.
You have the right to be notified by our office of any breech of privacy of your Protected Health Information.
Certain treatments may be performed in common therapy area and/or you may find yourself within public areas within the clinic time, but please note private rooms are always available, upon request, for discussing your private health information.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
C. Complaints
You may complain to us, or the Secretary of Health and Human Services, if you believe your privacy right have been violated by us. To file a complaint you may go to:
https://www.hhs.gov/sites/default/files/hip-complaint-form-0945-0002exp-04302019.pdf
Or our office can provide you with a written form in which to file your complaint. You may also file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against your for filing a complaint.
Our Privacy Offer is Hannelie van der Merwe you may contact our Privacy Officer, or any staff member, including Colene Beck at the following phone number 479-304-8202 or our website for further information about the complaint process.
This notice was published and becomes effective on February 1, 2016
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