NOTICE OF PRIVACY PRACTICES

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: Dr. Jan Roberts.

This Notice of Privacy Practices describes how we may use and disclose your protected
health information to carry out treatment, payment or health care operations and for
other purposes that are permitted or required by law. It also describes your rights to
access and control your protected health information. “Protected health information”
(PHI) is information about you, including demographic information, that may identify you
and that relates to your past, present or future physical or mental health or condition and
related health care services. We are required 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. Upon
your written request, we will provide you with any revised Notice of Privacy Practices
or by calling the office and requesting that a revised copy be sent to you in the mail or
asking for one at the time of your next appointment.

1. Uses and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, 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 PHI may also be used and
disclosed to pay your health care bills and to support the operation of the physician’s practice.

Following are examples of the types of uses and disclosures of your PHI that the physician’s
office is permitted to make. 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 PHI 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 PHI protected. For example, we would disclose your PHI, as necessary,
to a home health agency that provides care to you. We will also disclose PHI to
other physicians who may be treating you when we have the necessary permission from
you to disclose your PHI. For example, your PHI 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 PHI from time-to-time to
another physician or health care provider (e.g., a specialist or laboratory) who, at the
request of your physician, becomes involved in your care by providing assistance with
your health care diagnosis or treatment to your physician.

Payment: Your PHI will be used, as needed, to obtain payment for your health care
services. This may include 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 you for medical necessity, and undertaking utilization
review activities. For example, obtaining approval for extended chiropractic care that
your relevant PHI be disclosed to the health plan to obtain approval for that care.  Dates and
costs of services information may be disclosed to a third party when attempting to collect
past due payments from you.

Email: We place email links on this site to allow you to contact us directly. The information
you provide is used to respond directly to your questions or comments. We may also file
your comments to improve the site and our services, or review and discard the information.
Healthcare Operations: We may use or disclose, as-needed, your PHI in order to support
the business activities of your physician’s practice. These activities include, but are not
limited to, quality assessment activities, employee review activities, training of staff,
chiropractic students, and chiropractic assistants for training fundraising activities,
and conducting or arranging for other business activities.

For example, we may disclose your PHI to chiropractic school students and
chiropractic assistants that see or assist our 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 if we need to change any information we currently have on file. We may
also call you by name in the waiting room when your physician is ready to see you. We
may use or disclose your PHI, as necessary, to contact you to remind you of your
appointment. We may leave a message regarding specifics of the time and
date of appointment with any person or devise who answers at the phone number of
record for you.  We will share your PHI with third party “business associates” that may
at any time 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 PHI, we will have a written contract that contains terms
that will protect the privacy of your PHI. We may use or disclose your demographic
information and the dates that you received treatment from your physician, as
necessary, in order to contact you for fundraising activities supported by our office. If
you do not want to receive these materials, please contact our Privacy Contact and
request in writing that these fundraising materials not be sent to you.

Uses and Disclosures of Protected Health Information Based upon Your
Written Authorization

Other uses and disclosures of your PHI will be made only with your written
authorization, unless otherwise permitted or required by law as described below. You
may revoke this authorization, at any time, in writing, except to the extent that your
physician or the physician’s practice has 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

We may use and disclose your PHI in the following instances. You have the
opportunity to agree or object to the use or disclosure of all or part of your PHI. If you are
not present or able to agree or object to the use or disclosure of the PHI, then your
physician may, using professional judgment, determine whether the disclosure is in your
best interest. In this case, only the PHI that is relevant to your health care will be disclosed.

Facility Directories: Unless you object, to people that ask for you by name,
(either in person or by telephone or electronic means), we will use and disclose verbally
that you are on the premises or not on the premises (or disclose when you are
expected or when you were last seen).  Anyone who asks about you by name regarding
your general condition or “how you are doing” will be told you are either 
“doing a little better” or “not doing too well”.  No specifics will be revealed except to those
friends and family members you have indicated are directly involved with your
healthcare, on the “Others Involved in My Healthcare Form” (see below). 

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 PHI
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 interest based on our professional judgment. We may
use or disclose PHI to notify or assist in notifying a family member, personal
representative or any other person that is responsible for your care of your location,
general condition . Finally, we may use or disclose your PHI 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 health care.  You may affix additional names of
family and friends (who may live at a distance or with whom the physician is not
personally familiar), to this list by requesting a copy of our Others Involved in My
Healthcare form.

Other Permitted and Required Uses and Disclosures That May Be Made Without
Your Authorization or Opportunity to Object

We may use or disclose your PHI in the following situations without your authorization.
These situations include:

Required By Law: We may use or disclose your PHI to the extent that the use or
disclosure is required by law. 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 PHI 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 PHI, 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 PHI, if authorized by law, to a person
who may have been exposed to a communicable disease or may otherwise be at
risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose PHI 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 PHI to a public health authority that is
authorized by law to receive reports of child abuse or neglect. In addition, we may disclose
your PHI if we believe that you have been a victim of abuse, neglect or domestic violence
to the governmental 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.

Food and Drug Administration: We may disclose your PHI to a person or company
required by the FDA to report adverse events, product defects or problems, biologic
product deviations, track products; to enable product recalls; to make repairs or
replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose PHI in the course of any judicial or administrative
proceeding, in response to an order of a court or administrative tribunal (to the extent such
disclosure is expressly authorized), in certain conditions in response to a subpoena,
discovery request or other lawful process.

Law Enforcement: We may also disclose PHI, so long as applicable legal requirements
are met, for law enforcement purposes. These law enforcement purposes include
(1) legal processes and otherwise required by law, (2) limited information requests
for identification and 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.

Coroners, Funeral Directors, and Organ Donation: We may disclose PHI to a coroner
or medical examiner for identification purposes, determining cause of death or for the
coroner or medical examiner to perform other duties authorized by law. PHI may be used
and disclosed for cadaveric organ, eye or tissue donation purposes.

Research: We may disclose your PHI to researchers when their research has been
approved by an institutional review board that has reviewed the research proposal
and established protocols to ensure the privacy of your PHI.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your
PHI, if we believe that the use or disclosure is necessary to prevent or lessen a serious
and imminent threat to the health or safety of a person or the public. We may also disclose
PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, we may
use or disclose PHI of individuals who are Armed Forces personnel (1) for activities
deemed necessary by appropriate military command authorities; (2) for the purpose
of a determination by the Department of Veterans Affairs of your eligibility for benefits, or
(3) to foreign military authority if you are a member of that foreign military services.
We may also disclose your PHI to authorized federal officials for conducting national
security and intelligence activities, including for the provision of protective services to
the President or others legally authorized.

Workers’ Compensation: Your PHI may be disclosed by us as authorized to comply with
workers’ compensation laws and other similar legally-established programs.

Inmates: We may use or disclose your PHI if you are an inmate of a correctional facility
and your physician created or received your protected health information in the
course of providing care to you.

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.

2. Your Rights

Following is a statement of your rights with respect to your PHI 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, upon written request, within ten business days, inspect and obtain a
copy of PHI about you that is contained in a designated record set for as long as we
maintain the PHI. You will be charged a reasonable fee for copying any records.  A
“designated record set” contains medical and billing records and any other records that
your physician and the practice uses for making decisions about you. While  seldom a
part of offices records forwarded by others to this physician, we must advise you that
under federal law, however, you may not inspect or copy the following records;
psychotherapy notes; information compiled 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 PHI. Depending on the circumstances, a
decision to deny access may be reviewable. In some circumstances, you may have a
right to have this decision reviewed. Please contact our Privacy Contact if you have
specific questions about access to your medical record.

You have the right to request a restriction of your protected health information.
This means you may ask us, in writing, not to use or disclose any part of your PHI for
the purposes of treatment, payment or healthcare operations. You may also request
that any part of your PHI 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. Your physician is not
required to agree to a restriction that you may request. If physician believes it is in
your best interest to permit use and disclosure of your PHI, your PHI will not be
restricted. If your physician does agree to the requested restriction, we may not use or
disclose your PHI in violation of that restriction unless it is needed to provide
emergency treatment. With this in mind, please discuss any restriction you wish to
request with your physician. You may request a restriction by requesting a form entitled
Others Involved in My Healthcare.

You have the right to request to receive confidential communications from
us by alternative means or at an alternative location (such as when traveling).
We will accommodate reasonable requests. We may also condition this
accommodation by asking you for information as to how payment (for such things as
long distance phone charges, etc.)  will be handled or specification of an alternative
address or other method of contact. We will not request an explanation from you as to
the basis for the request. Please make this request as needed, in writing, to our
Privacy Contact.

You may have the right to have your physician amend your protected
health information.
This means you may request an amendment of PHI about you in a designated record set
for as long as we maintain this information. This amendment can only be done to records
that the physician has personally created, not those received from other providers of
care.  In certain cases, we may deny your request for an amendment. If we deny your
request for 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. Both your request and our rebuttal will then become a part of your
personal record.  If you would like to request an amendment to a portion of the record that
was not created by this physician, that request and your explanation of the discrepancies
will be added to your chart and become a part of the record, but the cited information
itself will not be changed or purged.  Please contact our Privacy Contact to determine
if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures 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, for the facility, to family members or friends involved
in your care, or for notification purposes. You have the right to receive specific
information regarding these disclosures that occurred after April 14, 2003. You may
request a shorter timeframe. The right to receive this information is subject to
certain exceptions, restrictions and limitations.

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