Hiller Chiropractic Insurance Participation

Hiller Chiropractic is a participating provider with:

Blue Cross Blue Shield
Priority Health
MESSA
Medicare

Hiller Chiropractic will accept all Private Plans, such as:

United
Aetna
Cigna
Humana
Cofinity
etc.

Hiller Chiropractic Policies

Notice of Privacy Practices

We are required by federal and state law to maintain the privacy of your health information. We are also required to give you this Notice of Privacy Practices (NPP). We must follow the privacy practices in this notice effective April 14, 2003, and it will remain in effect until we replace it. We may change our privacy practices at anytime to comply with changes in applicable laws. Upon significant change that would affect your rights, we shall inform you, and make the updated NPP available.

Uses and Disclosures

We collect the following information: First and Last Name, Address, Home Phone Number, Work Phone Number, Employer, Social Security Number, Drivers License Number, Date of Birth, Next of Kin, Insurance Carrier, we may also collect, email address, cell phone / pager number, family information.

We may supply this information to a health care provider who will treat you.

We may supply this information to an insurance carrier to receive payment for services rendered.

We may supply this information to other healthcare professionals for purpose of continuing treatment, prescription drugs, health aids, consultation, evaluation, accreditation, certification, or licensing.

We may disclose this information if Required by Law. If we believe you are a possible victim of abuse, neglect, domestic violence, or a possible victim of other crimes, we may disclose your health information to avert a threat to your health, or the health and safety of others.

We may use this information to send you appointment reminders, such as postcards, letters, phone calls, or answering machine messages.

We may use this information to send you birthday, or holiday greetings.

Patient Rights

You have the right to view your health care information.

You may request a photocopy of your health information; the request must be in writing.

You have the right to receive a list of instances in which your information has been used for any reason other than those listed above.

You have the right to request, in writing, additional restrictions be placed on your information, or to rescind earlier consent.

You have the right to request to amend your health care information the written request must have a full explanation of the purpose of the amendment.

You have the right of alternate communication, to have all contact with this office and yourself at a location of your choosing, or with a guardian, or representative of your choosing, or to have communication with this office via alternate means. Example Mail, Fax, TTY, etc.

Complaints

We support your right to privacy. If you are concerned your privacy has been violated, please bring your concerns to our attention, preferably in writing. Immediate action will be taken to remedy the situation. If you have any questions about our privacy practices, access to your health information, or amendments to your health information, please contact us, in writing, at:

HILLER CHIROPRACTIC
2081 HILLER ROAD
WEST BLOOMFIELD, MI 48324
248.681.6804

If you are concerned that your privacy rights have been violated, or if you disagree with a decision made about access to your health information, or if you disagree with a decision made about an amendment to your health information. You may contact in writing,

US Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Telephone: 202-619-0257
Toll Free: 1-877-696-6775

Hiller Chiropractic Financial Policy

• We make every effort to inform patients of fees prior to providing service.

• Payment is expected upon receiving service unless other arrangements have been agreed upon.

• A copy of the offices charges is available upon request. We have made every effort to establish fees that are fair and reasonable.

• Patients covered by insurance are responsible for deductibles and co-payments for services outside of plan coverage.

• For patients with other insurance coverage, we will accept assignment and bill the carrier. Patients may be responsible for any unpaid portion of the billing in addition to deductibles and co-payments.

• If a patient is unable to pay the fee, alternative arrangements can be made by discussing the situation with Dr. Rosenberg or the billing staff.


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