Notice of Privacy Practices for Chiropractic Care

[Practice Name] Chiropractic Care

Effective Date: [Date]

Our Commitment to Your Privacy

This notice describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully.

Protected Health Information (PHI)

We understand that your health information is personal, and we are committed to protecting it. We create a record of the care and services you receive at our practice, which we need to provide you with quality care and to comply with legal requirements.

Use and Disclosure of Your PHI

We May Use and Share Your Information for:

• Treatment purposes
• Payment processing
• Healthcare operations
• Appointment reminders
• Treatment alternatives
• Health-related benefits and services

Special Circumstances Requiring Disclosure:

• Public health and safety issues
• Research purposes (with your authorization)
• Legal requirements and law enforcement
• Workers' compensation claims

Your Rights Regarding Your PHI

You have the right to:

• Get a copy of your paper or electronic medical record
• Request corrections to your medical record
• Request confidential communications
• Ask us to limit the information we share
• Get a list of those with whom we've shared your information
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Changes to This Notice

We reserve the right to change this notice and make the new notice apply to PHI we already have as well as any information we receive in the future.

Contact Information

Privacy Officer: [Name] Phone: [Phone Number] Address: [Practice Address]

Patient Acknowledgment

I acknowledge that I have received a copy of this Notice of Privacy Practices.

Patient Signature

Date