Gilbert Chiropractic

Revised 4/24/14

PLEASE REVIEW THIS NOTICE CAREFULLY. This notice describes how chiropractic and medical information about you may be used and disclosed and how you may gain access to this information.

Policy statement

This Notice details how this practice is committed to maintaining the privacy of your PHI (protected health information). Your PHI includes information about your medical condition, the care and treatment you receive from the practice and other health care providers. This Notice describes how your PHI may be used in the following ways:

  • To third parties for purposes of your care

  • Payment for your care

  • Health care operations of the practice

  • Other purposes permitted or required by law

This Notice will also inform you of your rights regarding your PHI.

Gilbert Chiropractic may use or disclose personal health information about you in the following ways:

Examples of the types of uses and/or disclosure of you PHI that may occur are as follows. Gilbert Chiropractic may use or disclose you PHI for these purposes related to your care, payment, and health care operations of the practice.

  • CARE: in order to provide care to you, Gilbert Chiropractic will provide your PHI to those health care professionals directly involved in your care so they may understand your medical condition and needs to provide advice or treatment. An example would be a physician who may need to know how your condition is responding to the treatment provided to you by this Practice.

  • PAYMENT: in order to get paid for some or all of the health care provided to you by Gilbert Chiropractic, the Practice may provide you PHI, directly or through a billing service, to appropriate third party payers, pursuant to their billing and payment requirements they may have. An example would be the Practice providing your health insurance carrier with information about your health care services you received from Gilbert Chiropractic so that we may be properly reimbursed.


In the following ways Gilbert Chiropractic may use and/or disclose you PHI without written Authorization from you:

  • Business Associate: to a business associate, who is someone the Practice contracts with to provide service necessary for your treatment, payment for your treatment and/or health care operations. The Practice will obtain satisfactory written assurance, in accordance with applicable law. The business associate and subcontractor will appropriately safeguard your PHI.

  • Public Health Activities: such activities included information collected by a public health authority, as authorized by law, to prevent or control disease, injury or disability. Reports of child abuse or neglect is an example.

  • 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 disclosure, it will do so if it believes the disclosure is necessary to prevent serious harm or in the practice believes you have been the victim of abuse, neglect or domestic violence, any such disclosure will be made in accordance with their requirements of law, which may also involve notice to you of the disclosure.

  • Family and Friends: Unless expressly prohibited by you, Gilbert Chiropractic may disclose PHI to a member of your family, a close friend, a relative, or anyone you identify if it directly relates to that person’s involvement in your health care. If you do not express an objection or are unable to object to such a discloser, we may disclose the information, as necessary, if we determine or feel that it is in your best interest based on professional judgment.

  • Law Enforcement Purposes: In some cases, your PHI may have to be disclosed to a law enforcement official for law enforcement purposes. Those purposes include complying with a legal process (example: subpoena) or as required by law, information for identification and location (example: missing person or a suspect in a crime), information regarding a person who is or is suspected to be a crime victim, in situations where the death of an individual may have resulted from criminal conduct, or in the event of a crime occurring on the premises of the Practice, and a medical emergency(not on the property of the Practice) has occurred and it appears that a crime occurred.

  • De identified Information: your PHI is altered so that it does not identify you in any way and, even without your name, cannot be used to identify you.

  • Federal Drug Administration: if required by the Food and Drug Administration to report adverse events, product defects, problem’s, biological product deviations, or to track product, enable product recalls, repairs or replacements, or to conduct post marketing surveillance’s.

  • Judicial and Administrative Proceeding: an example of this would be if the practice is required to disclose your PHI in response to a court order or a lawfully issued subpoena.

  • Personal Representative: to a person who, under applicable law, has the authority to represent you in making decisions related to your health care.

  • Health Oversight Activities: Such activities, which must be required by law, involve government agencies involved in oversight activities that relate to the health care system, government benefit progress, government regulatory programs and civil rights law. Those activities included criminal investigations, audits, disciplinary actions, or general oversight activities relating to the community’s health care system.

  • Inmates: the practice may disclose your PHI to a correctional institution or a law enforcement official if you are an inmate of that correctional facility and your PHI is necessary to provide care and treatment to you or is necessary for the health and safety of other individuals or inmates.

  • Avert a Threat to Health or Safety: The Practice may disclose your PHI if it believes that such disclosure is necessary to protect or lessen 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.

  • Workers’ Compensation: if you are involved in a workers’ compensation claim the Practice may be required to disclose you PHI to an individual or entity that is part of the Workers’ Compensation System.

  • Marketing: Face to face communication directly with the patient, treatment and coordination of care activities, or communication about supplemants that have already been prescribed, or promotional gifts of nominal value do not require authorization as long as the practice receives no financial remuneration for making the communication,. All other situations require separate authorization.

  • Disaster Relief Efforts: The Practice may use or disclose you PHI to a public or private entity authorized to assist in disaster relief efforts.

  • Required by Law: if otherwise required by law, but such use or disclosure will be made in compliance with the law and limited to the requirements of the law.


Uses and/or disclosures, other than those described above, will be made only with your WRITTEN authorization. These may be revoked at any time, however, we cannot take back disclosures already made with your permission.

We also will NOT use or disclose your PHI for the following without written authorization:

  • Specially protected information- certain types of information such as psychotherapy notes, HIV status, substance abuse, mental health and genetic testing information require their separate written authorization for the purposes of treatment, payment or healthcare operations. Marketing or sales.


Gilbert Chiropractic may contact you to provide appointment reminders from time to time. The reminder may be in the form of a letter, postcard, or by phone messages. The practice will try to minimize the amount of information contained in the reminder. Gilbert Chiropractic may contact you about treatment alternatives it offers, or other health benefits or services that may be of interest to you.


You have the right to:

  • Restrict disclosures to your health plan when you have paid out-of-pocket in full for health care items or services provided by Gilbert Chiropractic.

  • Inspect and copy your PHI as provided by law. To inspect and copy you PHI, you must submit a written request to the Practice’s Privacy Officer. In certain situations that are defined by law, Gilbert Chiropractic may deny your request, but you will have the right to have the denial reviewed. Gilbert Chiropractic may charge you a fee (to cover costs incurred by the Practice to reproduce records)

  • Receive an accounting of non-routine disclosures of your PHI as provided by law. To request an accounting, you must submit a written request to the Practice’s Privacy Officer. The request must state a time period which may not be longer than seven years and may not include the dates before. The request should indicate in what form you want the list (paper or electronic). The Practice may charge you for the cost of providing this list. The Practice will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred.

  • Receive confidential communications of PHI by alternative means or at alternative locations, you must make your request in writing to the Privacy Officer. Gilbert Chiropractic will accommodate all reasonable requests.

  • Amend your PHI as provided by law. To request an amendment, you must submit a written request to the Privacy Officer with 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 originating 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 Practices denial, you have the right to submit a written statement of disagreement.

  • Receive a paper copy of this notice of Privacy Practices from the practice upon request.

  • To file a complaint with the Practice, contact the privacy officer. All complaints must be in writing. If your complaint is not resolved you have the right to contact the Secretary of Health and Human Service, Office for Civil Rights.

  • To obtain more information, or have your questions about our rights answered, please contact the Practice Privacy Officer.

The Practice requirements are as follows:

We are required by law to maintain the privacy of you PHI and provide you with a Notice of Privacy Practices upon request, abide by the terms of this Notice of Privacy Practice, reserves the right to change the terms of this Notice of Privacy Practice and to make the new Privacy Practice provisions effective for all your PHI that it maintains, not retaliate against you for making a complaint, make good faith efforts to obtain from you the Acknowledgment of receipt of this Notice, post this notice in the lobby and on the website, and inform you in a timely manner if there is a breach of unsecured health information.