This chapter applies to licensed chiropractors and registered chiropractic assistants. In this chapter, the following terms have the meanings indicated. Terms Defined. “Chiropractic assistant” means an individual who is registered by the Board to perform the duties authorized under COMAR 10.43.07. “Chiropractor” means an individual licensed by the Board: To practice chiropractic; or To practice chiropractic with the right to practice physical therapy. “Non-bona-fide treatment” means when a chiropractor or chiropractic assistant treats or examines a patient in a way that involves sexual contact, but there is no medical reason for the procedure, or the procedure falls outside the scope of reasonable chiropractic practices. “Sexually exploitative relationship” means when sexual contact occurs in an existing therapeutic relationship or within a period of time after formal termination of the relationship when the patient may still be vulnerable to the power imbalance that exists in the practitioner-patient relationship, even if the relationship may appear to be or is mutually consensual. “Therapeutic deception” means when a chiropractor or chiropractic assistant misrepresents sexual conduct as a legitimate form of treatment. A chiropractor and chiropractic assistant shall concern themselves primarily with the welfare of the patient. A chiropractor or chiropractic assistant who suffers from a physical, mental, or emotional impairment, including chemical abuse, that impacts the individual's ability to practice chiropractic or provide chiropractic assistance shall seek professional treatment and refrain from the practice of chiropractic or the practice of chiropractic assistance until the impairment no longer exists or reasonable accommodations can be made. A chiropractor and chiropractic assistant shall: Use professional discretion and integrity in relationships with a member of the health care community; Be professional in conduct, with honesty, integrity, self-respect, and fairness; Remain free from conflict of interest while fulfilling the objectives and maintaining the integrity of the chiropractic profession; Provide accurate fee information to the patient, the individual responsible for payment for treatment, and the insurer; At all times respect the patient's dignity, autonomy, and privacy; Practice chiropractic only as defined in the scope of practice set forth in Health Occupations Article, §3-101(f) and (g), Annotated Code of Maryland; Provide chiropractic assistance only within the parameters set forth in Health Occupations Article, §3-404, Annotated Code of Maryland, and COMAR 10.43.07; Cooperate with any lawful investigation conducted by the Board, including: Furnishing information requested in a timely manner as directed by the Board; Complying with a subpoena; Responding to a complaint at the request of the Board; and Providing meaningful and timely access to relevant patient records; and Report to the Board, or other appropriate authority, conduct in the practice of chiropractic that indicates a violation of: This chapter; Health Occupations Article, Title 3, Annotated Code of Maryland; or Any other law, including but not limited to aiding or abetting the unauthorized practice of chiropractic. A chiropractor or chiropractic assistant may not: Misrepresent credentials, qualifications, or affiliations and shall attempt to correct others who misrepresent the chiropractor's or the chiropractic assistant's credentials, qualifications, or affiliations; Knowingly engage in or condone behavior that is fraudulent, dishonest, or deceitful, or involves moral turpitude; Engage in a commercial activity which conflicts with the duties of a chiropractor and chiropractic assistant; Perform chiropractic on a patient if a contraindication against chiropractic treatment exists; Discriminate against a patient or a health care provider based on race, religion, age, gender, sexual orientation, national origin, or disability; Intimidate, threaten, influence, or attempt to influence any person regarding any violation of law or regulation; or Aid or abet any individual violating or attempting to violate any provision of law or regulation. A chiropractor shall: Use professional judgment in the use of evaluation and treatment procedures; Decline to administer treatment if the chiropractor believes that a treatment is contraindicated or unjustified; Terminate a professional relationship with a patient in an appropriate manner, such as: Providing the patient with sufficient notice to permit the patient to obtain the services of another professional; Assisting the patient by providing referrals if appropriate; or Continuing to provide emergency treatment to the patient if treatment is required before a reasonable time has passed to allow the patient to obtain the services of another health care provider; Maintain a written record of treatment of the patient under the chiropractor's care for at least: 5 years after the termination of treatment; and 5 years after the patient becomes 18 years old, if applicable; Make the written records of treatment available to the patient upon request, in compliance with applicable laws for disclosure of medical records; Make arrangements for another professional to provide for the needs of the patient during anticipated absences when the chiropractor is unavailable to the patient; Make referrals only to other qualified and duly licensed health care providers; Accurately inform the patient, other health care professionals, and the public of the limitations of the practice of chiropractic; Adequately assess the patient to determine if contraindications against chiropractic treatment exist and refer the patient to an appropriate health care practitioner; Exercise independent professional judgment in the treatment or evaluation of the patient regardless of whether the patient was referred by another health care provider; Ensure clear and concise professional communications with patients regarding: Nature and duration of treatment; Diagnoses; Costs; Billing; and Insurance; and Administer fair and equitable fees to patients regardless of status or insurance. A chiropractor may not: Accept a client for treatment, or continue unnecessary treatment, when the patient cannot be reasonably expected to benefit from the treatment; Receive remuneration from, or provide remuneration to, or split a fee, for either making or accepting a referral of the patient to or from another health care provider; Make a guarantee or promise about the efficacy of a particular treatment, the chiropractor's practice, or the result of a treatment unless supported by scientific principles accepted by the profession; or Exploit the professional relationship by: Continuing treatment unnecessarily; or Charging for a service: Not provided; or Different from those actually provided. A chiropractor and chiropractic assistant shall: Maintain professional boundaries, even when the patient initiates crossing the boundaries of the professional relationship; and Respect and maintain professional boundaries and respect the patient's reasonable expectation of professional conduct. A chiropractor and chiropractic assistant may not: Exploit a relationship with a patient, staff member, or student for the chiropractor's or chiropractic assistant's personal advantage including, but not limited to, a personal, sexual, romantic, or financial relationship; Engage in a sexually intimate act with a patient; or Engage in sexual misconduct, which includes but is not limited to: Therapeutic deception; Non-bona-fide treatment; and A sexually exploitative relationship. A chiropractor and chiropractic assistant may not engage in inappropriate behavior with other practice staff including sexual advances, harassment, discrimination, exploitation, retaliation, and other unprofessional conduct. A chiropractor shall: Respect and maintain the privacy and confidentiality of the patient; Disclose the patient’s records or information about the patient only: In accordance with the consent to treatment form signed by the: Patient; or Parent or guardian of a minor patient or incompetent patient; or As required by law. Adequately safeguard confidential patient information, including storage and disposal of records; Provide sufficient information to a patient to allow the patient to make an informed decision regarding treatment, including: The purpose and nature of an evaluation or treatment regimen; Alternatives to treatment; Side effects and benefits of a treatment regimen proposed and alternatives to that treatment; The estimated cost of treatment and alternatives to treatment; The right of the patient to: Withdraw from treatment at any time, including the risks associated with withdrawing from treatment; Decline to participate in treatment if an aspect of the treatment will be recorded, documented, photographed, observed, or otherwise used in an educational program; or Terminate any treatment contract at any time, for any or no reason, with no fee or penalty incurred; Obtain the full informed consent of a patient participating in a human research program, without communicating a direct or implied penalty for the patient's refusal to participate in the program and with due regard for the patient's autonomy and dignity; Comply with applicable federal and State laws for human research programs; and Promptly and efficiently respond to any patient or Board request for records. A chiropractor or chiropractic assistant shall: Obtain additional training, information, and supervision as needed to perform a new technique or service in a new specialty area or when employing a new treatment modality; and Be current in the qualifications to practice, including meeting continuing education requirements established by the Board. The chiropractor or chiropractic assistant may not perform a treatment or provide a service that the chiropractor or chiropractic assistant is not qualified to perform or which is beyond the scope of the chiropractor's or chiropractic assistant’s education, training, capabilities, experience, and scope of practice. A chiropractor may advertise services subject to COMAR 10.43.03. A chiropractor is accountable under this regulation if the chiropractor uses an agent, partnership, professional association, or health maintenance organization to implement an action prohibited by COMAR 10.43.03.05. A chiropractor and chiropractic assistant may not construe any failure to specify a particular ethical, legal, or professional duty in this chapter as a denial of the existence of other ethical, legal, or professional duties or responsibilities that are equally as important and generally recognized in the chiropractic profession. Violation of a regulation in this chapter may result in the Board taking action pursuant to Health Occupations Article, §3-313, Annotated Code of Maryland. Health Occupations Article, §§1-212, 3-205, and 3-313, Annotated Code of Maryland Effective date: January 9, 2000 (26:27 Md. R. 2015) Regulation .03B, D amended effective October 22, 2007 (34:21 Md. R. 1915) Regulation .03C amended effective January 6, 2014 (40:26 Md. R. 2164) Regulation .03D amended effective October 22, 2007 (34:21 Md. R. 1915); June 13, 2011 (38:12 Md. R. 705) Regulation .04A amended effective October 22, 2007 (34:21 Md. R. 1915) Regulation .05B amended effective January 6, 2014 (40:26 Md. R. 2164) Regulation .05C adopted effective January 6, 2014 (40:26 Md. R. 2164) Regulation .06D amended effective January 6, 2014 (40:26 Md. R. 2164) Regulation .06G adopted effective October 22, 2007 (34:21 Md. R. 1915) Regulation .07 amended effective June 13, 2011 (38:12 Md. R. 705) Chapter and Subtitle renamed and recodified from COMAR 10.43.14 to COMAR 10.43.13, Board of Chiropractic Examiners, Code of Ethics, effective January 2, 2017 (43:26 Md. R. 1446) Regulation .06B amended effective December 30, 2019 (46:26 Md. R. 1165)