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HIPPA
Notice of Privacy Practices
Back in Motion Spine and Wellness Clinic
and Neuro Diagnostic Centers Inc.
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.
Effective Date: April 1st , 2023
This Notice of Privacy Practices (“Notice”) applies to Back in Motion Spine and Wellness Clinic and Neuro Diagnostic Centers Inc. (collectively, “we,” “us,” or “the Practice”), our workforce members, and any affiliated providers or business associates who create, receive, maintain, or transmit protected health information (PHI) on our behalf.
We are required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations to maintain the privacy of your PHI, to provide you with this Notice of our legal duties and privacy practices, and to follow the terms of the Notice currently in effect.
Our Pledge Regarding Your Health Information
We understand that information about you and your health is personal. We are committed to protecting your PHI. We create a record of the care and services you receive so that we can provide quality care and comply with legal requirements. This Notice applies to all records of your care generated or maintained by the Practice.
How We May Use and Disclose Your Protected Health Information
We may use and disclose your PHI without your written authorization in the following circumstances:
Treatment. We may use and disclose PHI to provide, coordinate, or manage your chiropractic, wellness, spinal, neurodiagnostic, or related care. This includes sharing information with other health care providers involved in your treatment, such as physicians, therapists, or specialists, and for consultation or referral purposes.
Payment. We may use and disclose PHI to obtain payment for services we provide. This includes billing your health plan, determining eligibility or coverage, coordinating benefits, reviewing claims, and collection activities.
Health Care Operations. We may use and disclose PHI for our operational activities, including quality assessment and improvement, staff training and evaluation, licensing, accreditation, business planning, customer service, and auditing.
Other Permitted or Required Uses and Disclosures (without authorization, subject to applicable conditions):
- As required by law (including court orders, subpoenas, or statutes).
- For public health activities (e.g., reporting certain diseases or injuries, vital statistics).
- To report abuse, neglect, or domestic violence when required or authorized by law.
- For health oversight activities (audits, investigations, inspections by government agencies).
- For judicial and administrative proceedings.
- For law enforcement purposes under specified conditions.
- To coroners, medical examiners, or funeral directors.
- For organ, eye, or tissue donation purposes.
- For research under approved protocols or limited data set agreements.
- To avert a serious threat to health or safety.
- For specialized government functions (e.g., military, national security, correctional institutions).
- For workers’ compensation or similar programs.
- Incidental disclosures that occur as a byproduct of otherwise permitted uses (we use reasonable safeguards to limit these).
We will not use or disclose your PHI for marketing purposes or sell your PHI without your written authorization, except as permitted by law. We will not use genetic information for underwriting purposes.
Uses and Disclosures That Require Your Written Authorization
Most uses and disclosures of psychotherapy notes (if applicable), uses and disclosures for marketing, and disclosures that constitute a sale of PHI require your written authorization. Other uses and disclosures not described in this Notice will be made only with your written authorization. You may revoke an authorization at any time in writing, except to the extent we have already relied on it.
Your Rights Regarding Your Protected Health Information
You have the following rights:
- Right to Inspect and Copy. You may request to inspect or obtain a copy of your PHI in our designated record set (paper or electronic). We may charge a reasonable, cost-based fee. We may deny the request in limited circumstances; you may request a review of certain denials.
- Right to Amend. You may request that we amend PHI you believe is incorrect or incomplete. We may deny the request if we did not create the information, it is not part of our records, or we determine it is accurate and complete. You will be notified of the reason and how to file a statement of disagreement.
- Right to an Accounting of Disclosures. You may request a list of certain disclosures of your PHI made in the six years prior to the request (excluding disclosures for treatment, payment, operations, and certain others). The first accounting in a 12-month period is free; additional requests may incur a reasonable fee.
- Right to Request Restrictions. You may request that we restrict uses or disclosures of PHI for treatment, payment, or operations, or to persons involved in your care. We are not required to agree except when you pay out-of-pocket in full for a service and request that we not disclose related information to a health plan for payment or operations (we must agree in that case unless the disclosure is required by law).
- Right to Request Confidential Communications. You may request that we communicate with you by alternative means or at alternative locations (e.g., a different address or phone number). We will accommodate reasonable requests.
- Right to a Paper Copy of This Notice. You may request a paper copy of this Notice at any time, even if you agreed to receive it electronically.
- Right to Notification of a Breach. You have the right to be notified if a breach of your unsecured PHI occurs.
To exercise any of these rights, submit a written request to our Privacy Officer (contact information below). We will respond within the timeframes required by law (generally 30 days, with possible 30-day extension).
Our Duties
We are required to:
- Maintain the privacy and security of your PHI.
- Provide you with this Notice.
- Abide by the terms of the Notice currently in effect.
- Notify you of a breach of unsecured PHI as required by law.
- Obtain your written authorization for uses and disclosures not otherwise permitted.
We reserve the right to change our privacy practices and this Notice. Any revised Notice will apply to PHI we already have as well as future information. The current Notice will be posted in our offices and made available upon request. We will provide a copy of the revised Notice upon request or as required.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services.
To file a complaint with us:
Contact the Privacy Officer in writing at the address below. You will not be retaliated against for filing a complaint.
To file a complaint with HHS:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-800-368-1019
https://www.hhs.gov/hipaa/filing-a-complaint
Contact Information
For questions about this Notice, to exercise your rights, or to file a complaint, contact:
Privacy Officer
Back in Motion Spine and Wellness Clinic and Neuro Diagnostic Centers Inc.
[Insert primary clinic address, e.g., 766 Deltona Blvd, Deltona, FL 32725 for Neuro Diagnostic Centers Inc., or the applicable Back in Motion location]
Phone: 386.569.6549
Email: drsteve@neurodxc.com
Acknowledgment
You will be asked to acknowledge receipt of this Notice. Signing an acknowledgment does not waive any of your rights.
This document is provided as a sample Notice of Privacy Practices customized with the practice names you supplied. It is not legal advice. HIPAA requirements, state medical records laws (including Florida), and operational details can vary. Have a qualified healthcare attorney or HIPAA compliance professional review and adapt this Notice, insert accurate addresses/phone numbers/Privacy Officer details, confirm any organized health care arrangement or affiliated covered entity status, and ensure it matches your actual policies, procedures, and state-specific rules before use. Post the current Notice prominently and provide it to patients no later than the first service delivery.
Notice of Privacy Practices
Back in Motion Spine and Wellness Clinic
and Neuro Diagnostic Centers Inc.
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.
Effective Date: April 1st , 2023
This Notice of Privacy Practices (“Notice”) applies to Back in Motion Spine and Wellness Clinic and Neuro Diagnostic Centers Inc. (collectively, “we,” “us,” or “the Practice”), our workforce members, and any affiliated providers or business associates who create, receive, maintain, or transmit protected health information (PHI) on our behalf.
We are required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations to maintain the privacy of your PHI, to provide you with this Notice of our legal duties and privacy practices, and to follow the terms of the Notice currently in effect.
Our Pledge Regarding Your Health Information
We understand that information about you and your health is personal. We are committed to protecting your PHI. We create a record of the care and services you receive so that we can provide quality care and comply with legal requirements. This Notice applies to all records of your care generated or maintained by the Practice.
How We May Use and Disclose Your Protected Health Information
We may use and disclose your PHI without your written authorization in the following circumstances:
Treatment. We may use and disclose PHI to provide, coordinate, or manage your chiropractic, wellness, spinal, neurodiagnostic, or related care. This includes sharing information with other health care providers involved in your treatment, such as physicians, therapists, or specialists, and for consultation or referral purposes.
Payment. We may use and disclose PHI to obtain payment for services we provide. This includes billing your health plan, determining eligibility or coverage, coordinating benefits, reviewing claims, and collection activities.
Health Care Operations. We may use and disclose PHI for our operational activities, including quality assessment and improvement, staff training and evaluation, licensing, accreditation, business planning, customer service, and auditing.
Other Permitted or Required Uses and Disclosures (without authorization, subject to applicable conditions):
- As required by law (including court orders, subpoenas, or statutes).
- For public health activities (e.g., reporting certain diseases or injuries, vital statistics).
- To report abuse, neglect, or domestic violence when required or authorized by law.
- For health oversight activities (audits, investigations, inspections by government agencies).
- For judicial and administrative proceedings.
- For law enforcement purposes under specified conditions.
- To coroners, medical examiners, or funeral directors.
- For organ, eye, or tissue donation purposes.
- For research under approved protocols or limited data set agreements.
- To avert a serious threat to health or safety.
- For specialized government functions (e.g., military, national security, correctional institutions).
- For workers’ compensation or similar programs.
- Incidental disclosures that occur as a byproduct of otherwise permitted uses (we use reasonable safeguards to limit these).
We will not use or disclose your PHI for marketing purposes or sell your PHI without your written authorization, except as permitted by law. We will not use genetic information for underwriting purposes.
Uses and Disclosures That Require Your Written Authorization
Most uses and disclosures of psychotherapy notes (if applicable), uses and disclosures for marketing, and disclosures that constitute a sale of PHI require your written authorization. Other uses and disclosures not described in this Notice will be made only with your written authorization. You may revoke an authorization at any time in writing, except to the extent we have already relied on it.
Your Rights Regarding Your Protected Health Information
You have the following rights:
- Right to Inspect and Copy. You may request to inspect or obtain a copy of your PHI in our designated record set (paper or electronic). We may charge a reasonable, cost-based fee. We may deny the request in limited circumstances; you may request a review of certain denials.
- Right to Amend. You may request that we amend PHI you believe is incorrect or incomplete. We may deny the request if we did not create the information, it is not part of our records, or we determine it is accurate and complete. You will be notified of the reason and how to file a statement of disagreement.
- Right to an Accounting of Disclosures. You may request a list of certain disclosures of your PHI made in the six years prior to the request (excluding disclosures for treatment, payment, operations, and certain others). The first accounting in a 12-month period is free; additional requests may incur a reasonable fee.
- Right to Request Restrictions. You may request that we restrict uses or disclosures of PHI for treatment, payment, or operations, or to persons involved in your care. We are not required to agree except when you pay out-of-pocket in full for a service and request that we not disclose related information to a health plan for payment or operations (we must agree in that case unless the disclosure is required by law).
- Right to Request Confidential Communications. You may request that we communicate with you by alternative means or at alternative locations (e.g., a different address or phone number). We will accommodate reasonable requests.
- Right to a Paper Copy of This Notice. You may request a paper copy of this Notice at any time, even if you agreed to receive it electronically.
- Right to Notification of a Breach. You have the right to be notified if a breach of your unsecured PHI occurs.
To exercise any of these rights, submit a written request to our Privacy Officer (contact information below). We will respond within the timeframes required by law (generally 30 days, with possible 30-day extension).
Our Duties
We are required to:
- Maintain the privacy and security of your PHI.
- Provide you with this Notice.
- Abide by the terms of the Notice currently in effect.
- Notify you of a breach of unsecured PHI as required by law.
- Obtain your written authorization for uses and disclosures not otherwise permitted.
We reserve the right to change our privacy practices and this Notice. Any revised Notice will apply to PHI we already have as well as future information. The current Notice will be posted in our offices and made available upon request. We will provide a copy of the revised Notice upon request or as required.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services.
To file a complaint with us:
Contact the Privacy Officer in writing at the address below. You will not be retaliated against for filing a complaint.
To file a complaint with HHS:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
1-800-368-1019
https://www.hhs.gov/hipaa/filing-a-complaint
Contact Information
For questions about this Notice, to exercise your rights, or to file a complaint, contact:
Privacy Officer
Back in Motion Spine and Wellness Clinic and Neuro Diagnostic Centers Inc.
[Insert primary clinic address, e.g., 766 Deltona Blvd, Deltona, FL 32725 for Neuro Diagnostic Centers Inc., or the applicable Back in Motion location]
Phone: 386.569.6549
Email: drsteve@neurodxc.com
Acknowledgment
You will be asked to acknowledge receipt of this Notice. Signing an acknowledgment does not waive any of your rights.
This document is provided as a sample Notice of Privacy Practices customized with the practice names you supplied. It is not legal advice. HIPAA requirements, state medical records laws (including Florida), and operational details can vary. Have a qualified healthcare attorney or HIPAA compliance professional review and adapt this Notice, insert accurate addresses/phone numbers/Privacy Officer details, confirm any organized health care arrangement or affiliated covered entity status, and ensure it matches your actual policies, procedures, and state-specific rules before use. Post the current Notice prominently and provide it to patients no later than the first service delivery.
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