Trilogy Chiropractic – 887 62nd St Cir E #101, Lakewood Ranch, FL 34208

Dr. Paul Cundiff, D.C. – (941) 404-7684

Effective Date: [Effective Date]

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED, DISCLOSED, AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE READ IT CAREFULLY.

At Trilogy Chiropractic, we are dedicated to safeguarding your privacy and ensuring the confidentiality of your medical information. We create a record of the care provided and may receive records from other healthcare providers. These records are used to deliver quality chiropractic care, obtain payment for services, comply with legal obligations, and operate our practice effectively. By law, we must maintain the privacy of protected health information, provide you with this notice of our legal duties and privacy practices, and notify you in case of a breach of unsecured protected health information. This notice explains how we may use and share your medical information, your rights, and our responsibilities concerning your information. If you have any questions, please contact Dr. Paul Cundiff, our Privacy Officer, at the abovementioned phone number.

CONTENTS

1. How We May Use or Share Your Health Information
2. Situations Where We May Not Use or Share Your Health Information
3. Your Health Information Rights
   a. Requesting Special Privacy Protections
   b. Requesting Confidential Communications
   c. Inspecting and Copying Your Information
   d. Amending or Supplementing Your Information
   e. Obtaining an Accounting of Disclosures
   f. Receiving a Paper or Electronic Copy of this Notice
4. Changes to this Privacy Notice
5. Filing a Complaint
6. How We May Use or Share Your Health Information

Treatment: We may use your health information to provide and coordinate your chiropractic care. We may share information with other healthcare providers involved in your treatment.

Payment: We may use and share your information to bill and receive payment from health plans or other entities for our chiropractic services.

Healthcare Operations: We may use and share your information for our practice operations, such as quality improvement, staff training, and compliance purposes.

Appointment Reminders and Health-Related Benefits: We may contact you to provide appointment reminders or information about treatment alternatives and health-related benefits that may interest you.

Individuals Involved in Your Care: We may share your information with family members or others involved in your care or payment for your care, as permitted by law or based on your consent.

Legal Requirements and Public Health: We may disclose your information when required by law, such as for public health purposes, abuse or neglect reporting, health oversight activities, and in response to court orders.

Other Purposes: To avert a serious threat to health or safety, we may use or share your information for other purposes, such as research (with your consent or when identifying information is removed).

1. Situations Where We May Not Use or Share Your Health Information

Except as this notice describes, we will not use or share your information without your written authorization. You may revoke your authorization at any time in writing, and we will stop using or sharing your information for the reasons covered by your authorization.

1. Your Health Information Rights

1. Requesting Special Privacy Protections: You have the right to request restrictions on how we use and share your information. We will consider all requests but may only be able to comply with some restrictions.
2. Requesting Confidential Communications: You may request that we contact you in a specific way or at a certain location. We will accommodate reasonable requests.
3. Inspecting and Copying Your Information: You have the right to inspect and obtain a copy of your health information, with some exceptions. We may charge a reasonable fee for copying and mailing.
4. Amending or Supplementing Your Information: If you believe your health information needs to be corrected or completed, you may request an amendment. We may deny your request in certain situations but will provide you with an explanation.
5. Obtaining an Accounting of Disclosures: You have the right to request a list of instances where we have disclosed your information for reasons other than treatment, payment, or healthcare operations. We will provide the first accounting within 12 months for free but may charge for additional requests.
6. Receiving a Paper or Electronic Copy of this Notice: You have the right to receive a paper copy of this notice and may request an electronic copy as well.

1. Changes to this Privacy Notice

We reserve the right to change this notice and will post the current notice on our website and in our practice. The revised notice will apply to all information we maintain.

1. Filing a Complaint

If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer, Dr. Paul Cundiff, or the U.S. Department of Health and Human Services Office for Civil Rights. You will not face retaliation for filing a complaint.

To file a complaint with our office, contact Dr. Paul Cundiff at the above address or phone number.

To file a complaint with the Department of Health and Human Services, contact:

Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 1-877-696-6775
www.hhs.gov/ocr/privacy/hipaa/complaints/