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This notice describes how your health information may be used and how you can gain access to this
information. Please review it carefully.

Our Promise To You Our Valued Patient…..

This is not meant to alarm you. Quite the opposite we want to assure you that we take the new Federa
[HIPPA-Health Insurance Portability and Accountability Act] laws seriously. These laws were written to protect
the confidentiality of your health information. We trust you will never delay treatment in our offices because of
fear that your personal health information might be unnecessarily disclosed to others outside our office.

Why A Privacy Policy Now?

The most significant variable that has motivated the Federal Government to legally enforce the privacy of
health information is the rapid evolution of the use of electronic technology in the administration of healthcare
business. The government has appropriately sought to standardize and protect the electronic exchange of
your health information. This has challenged us to review not only how your information is used within our
computers but also with the Internet, phones, fax machines and any device used to copy or transfer that
data.We want to advise you that we have developed policies and procedures for our practice to assure that
your personal or health information will be shared only as required and only for the purpose of administering
your case.

Our office is subject to State and Federal laws regarding the confidentiality of your health
information and we will assure adherence to those laws and we want you to understand our procedures and
your rights as a valued patient.Your health information will be communicated only for the purpose of obtaining
payment for services and conducting healthcare business. Be assured that without your written permission,
you health information will not be used for any other purpose.

How Your Health Information May Be Used To Provide Treatment

Within our office, your health information will be used to provide you the best care and services possible. This
may include administrative and clinical procedures designed to optimize scheduling and coordination between
you and all office personnel. In addition, we may share this information with referring physicians, clinical
pathology laboratories or other health professionals providing you treatment.

To Obtain Payment

Your health information may be included with an invoice for the purpose of collecting payment for service
provided to you in this office. We may do this with insurance forms filed for you by mail or electronically. We
will make all effort to work with companies with a similar commitment to the security of your health information.

To Conduct Healthcare Operations

Your health information may be used during performance evaluations of our staff. Some of our best teaching
opportunities use clinical situations experienced by patients receiving care in our office. As a result, your
health information may be included in the training programs for students, interns, associates, as well as
business and clinical employees. It is also possible that your health information will be disclosed during audits
by insurance companies or government appointed agencies as part of their quality assurance and compliance
reviews. Your health information may be reviewed during the routine process of certification, licensing or
credentialing activities.

In Patient Reminders

Because we believe regular care is very important to your general health, we will remind you of a scheduled
appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you
to follow up on your care and inform you of treatment options or services that may be of interest to you or
members of your family. These communications are an important part of our philosophy of partnering with our
patients to be sure they receive the best care chiropractic can provide. They may include postcards,
newsletters, flyers, telephone or electronic reminders such as e-mail [unless you tell us in writing that you
prefer not to receive reminders.]

Public Health and National Security

We may be required to disclose to Federal officials or military authorities health information necessary to
complete an investigation related to public health and or national security.

For Law Enforcement

As permitted or required by State or Federal law, we may disclose your health information to a proper
authorities for the purpose of law enforcement including under certain circumstances, if you are a victim of a
crime or in order to report a suspected crime.

Family, Friends and Caregivers

We may share your health information with those you tell us will be assisting you with your home hygiene,
care, treatment or payment. We will be certain to obtain your permission prior to sharing your information. In
the event of an emergency, where you are unable to tell us what you want, we will use our very best judgment
when sharing your health information with anyone participating in your care.

Medical Research

Advancing healthcare knowledge often involves learning from the careful study of health histories or prior
patients. Formal review and study of health histories as a part of research study will happen only under the
ethical guidance, requirements, and approval of an Institutional Review Board.

Authorization to Use or Disclose Health Information

Other than is stated above or where Federal, State or Local law requires us, we will not disclose your health
information other than with your written authorization. You may revoke that authorization in writing at any time.

Patient Rights

This law is careful to describe that you have the following rights related to your health information. Be assured
that our office will make every effort to honor reasonable restriction from our patients. Confidential
Communications You have the right to request that we communicate with you in a specific way. You may
request that we only communicate your health information privately with or without other family members
present or through sealed mail communications. We will make all reasonable effort to honor your request.

Inspect and Copy Your Health Information

You have the right to read, review and copy your health information, including your complete chart, x-rays and
billing records. If you would like a copy of your health information, please let us know. We may need to
charge you a reasonable fee to duplicate and assemble your copy.

Amend Your Health Information

You have the right to ask us to update or modify your records if you believe your health information in incorrect
or incomplete. We will be happy to accommodate you as long as our office maintains this information. In order
to standardize our process, please provide us with your request in writing and describe as completely as
possible your reason for the request. Your request may be denied if the health information record in question
was not created by our office, is not part of our records, or if the records containing your health information
have been requested sealed and or delivered to any authority for review.

Documentation of Health Information

You have the right to request from us a description of how and where your health information was used by our
office for any reason other than for treatment or payment, or healthcare operations. Our documentation
procedures will enable us to provide information on your health information usage from April 14, 2003 and
forward. Please let us know in writing the time period for which you are interested. We will greatly appreciate
you limiting your request to no more than six years at a time. We may need to charge you a reasonable fee for
your request.

Request a Paper Copy of this Notice

You have the right to request and obtain a copy of the Notice of Privacy Practices directly from our office at any
time. Just let us know of your request. We are required by law to maintain the privacy of your health
information and to provide to you and your representative this Notice of our Privacy Practices. We are required
to practice the policies and procedures described in this notice but we do reserve the right to change the terms
of our notice. Patients would be notified of any such changes.

You have the right to express concerns or
complaints to us or the Secretary of Health and Human Services if you believe your privacy rights have been
compromised. We encourage you to express in writing, any concerns you may have regarding the privacy of
your health information.

HIPAA Information and Consent Form

The Health Insurance Portability and Accountability Act [HIPAA] provides safeguards to protect your privacy.
Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our
practice for years. This form is a “friendly” version. A more complete text is posted in the office. What this is all
about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health
Information [PHI]. These restrictions do not include the normal interchange of information necessary to provide
you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these
needs with our goal of providing you with quality professional service and care. Additional information is
available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

  1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all
    administrative matters related to your care are handled appropriately. This specifically includes the sharing of
    information with other healthcare providers, laboratories, health insurance payers as is necessary and
    appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which
    identifies a patient’s condition or information which is not already a matter of public record. The normal course
    of providing care means that such records may be left, at least temporarily, in administrative areas such as the
    front office, examination room, etc. Those records will not be available to persons other than office staff. You
    agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and
    other documents or information.
  2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail,
    U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other
    communications informing you of changes to office policy and new technology that you might find valuable or
  3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to
    PHI but must agree to abide by the confidentiality rules of HIPAA.
  4. You understand and agree to inspections of the office and review of documents which may include PHI by
    government agencies or insurance payers in normal performance of their duties.
  5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manger or the
  6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods
    or services.
  7. We agree to provide patients with access to their records in accordance with state and federal laws.
  8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the
    practice and the patient.
  9. You have the right to request restrictions in the use of your protected health information and to request
    change in certain policies used within the office concerning your PHI. However, we are not obligated to alter
    internal policies to conform to your request.

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