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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