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Privacy Policy

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE

USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS

Our practices are dedicated, and we are required by applicable federal and state laws, to maintain

the privacy of your health information. These laws also require us to provide you with this

Notice of our privacy practices, and to inform you of your rights, and our obligations, concerning

your health information. We are required to follow the privacy practices described below while

this Notice is in effect. This Notice is effective as of 06/01/13, and will remain in effect until we

replace it.

CHANGES TO NOTICE:

We reserve the right to change this Notice and the privacy practices described below at any time

in accordance with applicable law. Prior to making significant changes to our privacy practices,

we will alter this Notice to reflect the changes, and make the revised Notice available to you on

request. Any changes we make to our privacy practices and/or this Notice may be applicable to

health information created or received by us prior to the date of the changes.

You may request a copy of our Notice at any time. For more information about our privacy

practices, or for additional copies of this Notice, please contact us using the information listed at

the end of this Notice.

PERMITTED USES AND DISCLOSURES OF HEALTH INFORMATION:

A. CONSENT: You should be aware that during the course of our relationship with you, we will

likely use and disclose health information about you for treatment, payment, and healthcare

operations. Examples of these activities are as follows:

Treatment: We may use or disclose your health information to another healthcare

provider or medical doctor providing treatment to you, so that we may coordinate, plan,

and manage your health care.

Payment: We may use and disclose your health information to obtain payment for

services we provide to you. We may provide your health information, directly or through

a billing service, to a third party who may be responsible for your care, including health

insurance companies and health plans.

Healthcare Operations: We may use and disclose your health information in connection

with our healthcare operations. Healthcare operations include quality assessment and

improvement activities, reviewing the competence or qualifications of healthcare

professionals, evaluating practitioner and provider performance, and other business

operations.

Our chiropractic practice will seek to obtain Consent from you permitting us to use or disclose

your health information for these activities. You should be aware that our chiropractic practice

does not require obtaining, or confirming the existence of a Consent, prior to:

a) Emergency treatment;

b) Treatment, when such treatment is required by law; or

c) Treatment of patients when communication barriers prevent obtaining Consent.

You should also be aware that you have the right to revoke that Consent at any time by providing

the practice with written notice.

B. AUTHORIZATIONS: You may specifically authorize us to use your health information for

any purpose or to disclose your health information to anyone, by submitting such an authorization

in writing. Upon receiving an authorization from you in writing we may use or disclose your

health information in accordance with that authorization. You may revoke an authorization at

any time by notifying us in writing. Your revocation will not affect any use or disclosures

permitted by your authorization while it was in effect. Unless you give us a written authorization,

we cannot use or disclose your health information for any reason except those permitted by this

Notice.

C. DISCLOSURES TO FAMILY AND PERSONAL REPRESENTATIVES: We must disclose

your health information to you, as described in the Patient Rights section of this Notice. Such

disclosures will be made to any of your personal representatives appropriately authorized to have

access and control of your health information. We may disclose your health information to a

family member, friend or other person to the extent necessary to help with your healthcare or with

payment for your healthcare only if authorized to do so. In the event of your incapacity or in

emergency circumstances, we will disclose health information based on a determination using our

professional judgment disclosing only health information that is directly relevant to the person’s

involvement in your healthcare.

D. MARKETING: We will not use your health information for marketing communications

without your written authorization.

E. USES OR DISCLOSURES REQUIRED BY LAW: We may use or disclose your health

information when we are required to do so by law, including for public health reasons (e.g.,

disease reporting). In some instances, and in accordance with applicable law, we may be required

to disclose your health information to appropriate authorities if we reasonably believe that you are

a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes.

F. PATIENT AND THIRD PARTY PROTECTION: Only as permitted by law, we may disclose

your health information to the extent necessary to avert a serious threat to your health or safety or

the health or safety of others.

G. LAW ENFORCEMENT/NATIONAL SECURITY: Under certain circumstances we may

disclose health information relating to members of the Armed Forces to military authorities.

Under certain circumstances we may also disclose health information relating to inmates or

patients to correctional institutions or law enforcement personnel having lawful custody of those

individuals. We may disclose health information in response to judicial proceedings and law

enforcement inquiries as permitted by law and to authorized federal officials health information

required for lawful intelligence, counterintelligence, and other national security activities.

H. APPOINTMENT REMINDERS: We may use or disclose your health information to

provide you with appointment reminders (such as voicemail messages or leaving a message with

the individual answering the phone, a postcard mailed to you at the address by you, or a letter).

PATIENT RIGHTS:

A. ACCESS TO RECORDS: Upon submission of a written request to us, you have the right to

review or receive copies of your health information, with limited exceptions. You may obtain a

form to request access by using the contact information listed at the end of this Notice. You may

request that we provide copies in a format other than photocopies and we will use the format you

request if it is readily available. We will charge you a reasonable cost-based fee relating to the

production of such copies. If you request copies, we will charge you $___ for each page, plus

postage, if you want the copies mailed to you. If you request an alternative format, we will

charge a reasonable cost-based fee for providing your health information in that format. If you

prefer, we will prepare a summary or an explanation of your health information for a fee. Contact

us using the information listed at the end of this Notice if you are interested in receiving a

summary of your information instead of copies.

B. ACCOUNTING OF CERTAIN DISCLOSURES. Upon written request, you have the right to

receive a list of instances in which we or our business associates disclosed your health

information for purposes, other than treatment, payment, healthcare operations and other

activities authorized by you, for the last 6 years, but not before April 14, 2003. If you request this

accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee

for responding to these additional requests.

C. RESTRICTIONS AND ALTERNATIVE COMMUNICATIONS: You have the right to

request that we place additional restrictions on our use or disclosure of your health information

for treatment, payment and healthcare operations purposes. Depending on the circumstances of

your request we may, or may not agree to those restrictions. If we do agree to your requested

restrictions we must abide by those restrictions, except in emergency treatment scenarios. You

have the right to request that we communicate with you about your health information by

alternative means or to alternative locations (e.g., at your place of business rather than at your

home). Such requests must be made in writing, must specify the alternative means or location,

and must provide satisfactory explanation how payments will be handled under the alternative

means or location you request.

D. AMENDMENTS TO RECORDS: You have the right to request that we amend your health

information. Such requests must be made in writing, and must explain why the information

should be amended. We may deny your request under certain circumstances.

E. ELECTRONIC NOTICES. If you receive this Notice on our Web site or by electronic mail

(e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please

contact us. If you are concerned that we may have violated your privacy rights, or you disagree

with a decision we made or any decisions we may make regarding the use, disclosure, or access

to your health information you may complain to us using the contact information listed below.

You also may submit a written complaint to the U.S. Department of Health and Human Services.

We will provide you with the address to file such a complaint upon request.

We support your right to the privacy of your health information. We will not retaliate in any way

if you choose to file a complaint with us or with the U.S. Department of Health and Human

Services.

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