NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
(45 CFR 164.520)
PLEASE REVIEW THIS NOTICE CAREFULLY.
This notice describes how medical information about you may be used and disclosed and you can get
access to that information as required by 45 CFR 164.520.
This Practice is committed to maintaining the privacy of your protected health information ("PHI"), which
includes information about your health condition and the care and treatment you receive from the
Practice. The creation of a record detailing the care and services you receive helps this office to provide
you with quality health care. This Notice details how your PHI may be used and disclosed to third parties.
This Notice also details your rights regarding your PHI. The privacy of PHI in patient files will be protected
when the files are taken to and from the Practice by placing the files in a box or brief case and kept within
the custody of a doctor or employee of the Practice authorized to remove the files from the Practice’s
office. It may be necessary to take patient files to a facility where a patient is confined or to a patient’s
home where the patient is to be examined or treated. This Notice may be amended or revised at which
time you will be provided the revised or amended Notice to review.
NO CONSENT REQUIRED
The Practice may use and/or disclose your PHI for the purposes of:
• (a) Treatment - In order to provide you with the health care you require, the Practice will provide
your PHI to those health care professionals, whether on the Practice's staff or not, directly involved in your
care so that they may understand your health condition and needs. For example, a physician treating you
for a condition or disease may need to know the results of your latest physician examination by this office.
• (b) Payment - In order to get paid for services provided to you, the Practice will provide your PHI,
directly or through a billing service, to appropriate third party payers, pursuant to their billing and
NOTICE OF PRIVACY PRACTICES Page 1 of 7payment requirements. For example, the Practice may need to
provide the Medicare program with information about health care services that you received from the Practice
so that the Practice can be properly reimbursed. The Practice may also need to tell your insurance plan about
treatment you are going to receive so that it can determine whether or not it will cover the treatment expense.
• (c) Health Care Operations - In order for the Practice to operate in accordance with applicable law
and insurance requirements and in order for the Practice to continue to provide quality and efficient care,
it may be necessary for the Practice to compile, use and/or disclose your PHI. For example, the Practice
may use your PHI in order to evaluate the performance of the Practice's personnel in providing care to
you.
1. The Practice may use and/or disclose your PHI, without a written Consent from you, in the following
additional instances:
(a) Any information is deleted that would identify you.
(b) To a company or person who is not employed by the practice to provide a service such as billing
insurance and/or electronic records. These persons/companies are called “Business Associates.” Only that
information necessary to perform the service will be submitted to the business associate if the Practice
obtains satisfactory written assurance, in accordance with applicable law, that the business associate will
appropriately safeguard your PHI.
(c) To a person that you designate as a personal representative who, under applicable law, has the
authority to represent you in making decisions related to your health care.
(d) Emergency Situations -
• (i) for the purpose of obtaining or rendering emergency treatment to you provided that the Practice
attempts to obtain your Consent as soon as possible; or
• (ii) to a public or private entity authorized by law or by its charter to assist in disaster relief efforts,
for the purpose of coordinating your care with such entities in an emergency situation.
(e) Communication Barriers - If, due to substantial communication barriers or inability to
communicate, the Practice has been unable to obtain your Consent and the Practice determines, in the
exercise of its professional judgment, that your Consent to receive treatment is clearly inferred from the
circumstances.
(f) Public Health Activities - Such activities include, for example, information collected by a public
health authority, as authorized by law, to prevent or control disease and that does not identify you and,
NOTICE OF PRIVACY PRACTICES Page 2 of 7even without your name, cannot be used to identify you.
(g) Abuse, Neglect or Domestic Violence - To a government authority if the Practice is required by
law to make such disclosure. If the Practice is authorized by law to make such a disclosure, it will do so if
it believes that the disclosure is necessary to prevent serious harm.
(h) Health Oversight Activities - Such activities, which must be required by law, involve government
agencies and may include, for example, criminal investigations, disciplinary actions, or general oversight
activities relating to the community's health care system.
(i) Judicial and Administrative Proceeding - For example, the Practice may be required to disclose
your PHI in response to a court order or a lawfully issued subpoena.
(j) Law Enforcement Purposes - In certain instances, your PHI may have to be disclosed to a law
enforcement official. For example, your PHI may be the subject of a grand jury subpoena. Or, the Practice
may disclose your PHI if the Practice believes that your death was the result of criminal conduct.
(k) Coroner or Medical Examiner - The Practice may disclose your PHI to a coroner or medical
examiner for the purpose of identifying you or determining your cause of death.
(l) Organ, Eye or Tissue Donation - If you are an organ donor, the Practice may disclose your PHI to
the entity to whom you have agreed to donate your organs.
(m) Research - If the Practice is involved in research activities, your PHI may be used, but such use
is subject to numerous governmental requirements intended to protect the privacy of your PHI and that
does not identify you and, even without your name, cannot be used to identify you.
(n) Avert a Threat to Health or Safety - The Practice may disclose your PHI if it believes that such
disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a
person or the public and the disclosure is to an individual who is reasonably able to prevent or lessen the
threat.
(o) Workers' Compensation - If you are involved in a Workers' Compensation claim, the Practice
may be required to disclose your PHI to an individual or entity that is part of the Workers' Compensation
system.
(p) Disclosure of immunizations to schools required for admission upon your informal agreement.
NOTICE OF PRIVACY PRACTICES Page 3 of 7APPOINTMENT REMINDER
The Practice may, from time to time, contact you to provide appointment reminders or information
about treatment alternatives or other health-related benefits and services that may be of interest to you.
Appointment reminders are used by the Practice. The Practice will use those methods which you
designate at the end of this Notice, such as: a) a postcard mailed to you at the address provided by you; b)
telephoning your home and leaving a message on your answering machine or with the individual
answering the phone; or sending you an email or text message.
INFORMATION PROTECTION/NO SALE OR DISTRIBUTION
Mobile opt in information will not be sold or shared with third parties for marketing purposes
SMS MESSAGING TERMS AND CONDITIONS
At Prime Care Chiropractic Centers, you can opt in to receive text notifications. These may include
appointment reminders, updates, and other information related to services provided by Prime Care
Chiropractic Centers. Messaging frequency varies. Standard message and data rates may apply. You can
opt out at any time by replying STOP or by contacting Prime Care Chiropractic Centers directly. For help,
text Options.
DIRECTORY/SIGN-IN LOG
The Practice maintains a directory of and sign-in log for individuals seeking care and treatment in
the office. Directory and sign-in log are located in a position where staff can readily see who is seeking
care in the office, as well as the individual's location within the Practice's office suite. This information
may be seen by, and is accessible to, others who are seeking care or services in the Practice's offices.
FAMILY/FRIENDS
The Practice may disclose to your family member, other relative, a close personal friend, or any
other person identified by you, your PHI directly relevant to such person's involvement with your care or
the payment for your care unless you direct the Practice to the contrary. The Practice may also use or
disclose your PHI to notify or assist in the notification (including identifying or locating) a family member,
a personal representative, or another person responsible for your care, of your location, general condition
or death. However, in both cases, the following conditions will apply:
• (a) If you are present at or prior to the use or disclosure of your PHI, the Practice may use or
disclose your PHI if you agree, or if the Practice can reasonably infer from the circumstances, based on the
exercise of its professional judgment that you do not object to the use or disclosure.
NOTICE OF PRIVACY PRACTICES Page 4 of 7• (b) If you are not present, the Practice will, in the exercise of professional judgment, determine
whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is directly
relevant to the person's involvement with your care.
AUTHORIZATION
Uses and/or disclosures, other than those described above, will be made only with your written
Authorization.
YOUR RIGHTS
1. You have the right to:
(a) Revoke any Authorization and/or Consent, in writing, at any time. To request a revocation, you
must submit a written request to the Practice's Privacy Officer.
(b) Request restrictions on certain use and/or disclosure of your PHI as provided by law. However,
the Practice is not obligated to agree to any requested restrictions. To request restrictions, you must
submit a written request to the Practice's Privacy Officer. In your written request, you must inform the
Practice of what information you want to limit, whether you want to limit the Practice's use or disclosure,
or both, and to whom you want the limits to apply. If the Practice agrees to your request, the Practice will
comply with your request unless the information is needed in order to provide you with emergency
treatment.
Restrictions from your health plan (insurance company): You have the right to request that we restrict
disclosure of your medical information to your health plan for covered services, provided the disclosure is
not required by other laws. Services must be paid in full by you, out of pocket.
(c) Receive confidential communications or PHI by alternative means or at alternative locations.
You must make your request in writing to the Practice's Privacy Officer. The Practice will accommodate all
reasonable requests.
(d) Inspect and obtain a copy your PHI as provided by 45 CFR 164.524. To inspect and copy your
PHI, you are requested to submit a written request to the Practice's Privacy Officer. The Practice can
charge you a fee for the cost of copying, mailing or other supplies associated with your request
(e) Amend your PHI as provided by 45 CFR 164.528. To request an amendment, you must submit a
NOTICE OF PRIVACY PRACTICES Page 5 of 7written request to the Practice's Privacy Officer. You must provide a reason that supports your request.
The Practice may deny your request if it is not in writing, if you do not provide a reason in support of your
request, if the information to be amended was not created by the Practice (unless the individual or entity
that created the information is no longer available), if the information is not part of your PHI maintained
by the Practice, if the information is not part of the information you would be permitted to inspect and
copy, and/or if the information is accurate and complete. If you disagree with the Practice's denial, you
will have the right to submit a written statement of disagreement.
(f) Receive an accounting of disclosures of your PHI as provided by 45 CFR 164.528. The request
should indicate in what form you want the list (such as a paper or electronic copy)
(g) Receive a paper copy of this Privacy Notice from the Practice upon request to the Practice's
Privacy Officer.
(h) Receive notice of any breach of confidentiality of your PHI by the Practice.
(i) Prohibit report of any test, examination or treatment to your health plan or anyone else for which you
pay in cash or by credit card.
(j) Complain to the Practice or to the Office of Civil Rights, U.S. Department of Health and Human
Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201, 202 619-
0257, email: [email protected] or to the Florida Attorney General, Office of the Attorney General, PL-01 The
Capitol, Tallahassee, FL 32399-1050, 850 414-3300 if you believe your privacy rights have been violated. To
file a complaint with the Practice, you must contact the Practice's Privacy Officer. All complaints must be
in writing.
(k) Request copies of your PHI in electronic format.
To obtain more information on, or have your questions about your rights answered; you may
contact the Practice's Privacy Officer, David Thomsen, at 863-294-3109 or via email at
PRACTICE'S REQUIREMENTS
1. The Practice:
• (a) Is required by federal law to maintain the privacy of your PHI and to provide you with this
Privacy Notice detailing the Practice's legal duties and privacy practices with respect to your PHI.
NOTICE OF PRIVACY PRACTICES Page 6 of 7• (b) Is required by State law to maintain a higher level of confidentiality with respect to certain
portions of your medical information that is provided for under federal law. In particular, the Practice is
required to comply with the following State statutes:
Section 381.004 relating to HIV testing, Chapter 384 relating to sexually transmitted diseases, Section
456.057 relating to patient records ownership, control and disclosure and Section 501.171 relating to
protecting your personal information, Social Security and driver license numbers, credit or debit card
information, financial accounts information, email address, and medical information.
• (c) Is required to abide by the terms of this Privacy Notice.
• (d) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy
Notice provisions effective for your entire PHI that it maintains.
• (e) Will distribute any revised Privacy Notice to you prior to implementation.
• (f) Will not retaliate against you for filing a complaint.
QUESTIONS AND COMPLAINTS
You may obtain additional information about our privacy practices or express concerns or
complaints to the person identified below whom is the Privacy Officer and Contact person appointed for
this practice. The Privacy Officer is Denise Kramer.
You may file a complaint with the Privacy Officer if you believe that your privacy rights have been
violated relating to release of your protected health information. You may, also, submit a complaint to the
Department of Health and Human Services the address of which will be provided to you by the Privacy
Officer. We will not retaliate against you in any way if you file a complaint.
EFFECTIVE DATE
This Notice is in effect as of 01/01/2026.