Privacy Statement

Rebarcak Chiropractic Pain Relief Center
Notice of Privacy Practices


Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have a
right to adequate notice of the uses and disclosures of your protected health information ("PHI")
(i.e., information that discloses your identity or leads to disclosure of your identity) that may be
made by this chiropractic practice. You are also entitled to notice of your rights and the duties of
this practice with respect to your personal health information.

Required by Law

All of the chiropractors and staff at our clinic have the following duties with respect to your
personal health information:
1) We are required by law to maintain the privacy of your personal health information.
2) We must provide you with notice of our legal duties and privacy practices with respect
to personal health information.
3) We must abide by the terms of the notice of privacy practices that is currently in effect.

How We May Use and Disclose Your Information

The following describes how our chiropractors and staff are permitted by law to share your
personal health information with others in order to provide you with chiropractic care. This notice
does not describe every use or disclosure our practice makes; it is intended as a general

Chiropractic Treatment. We may need to share information about you in order for any of our
chiropractors to provide care to you. For example, we may share information with other
chiropractors, medical doctors, nurses or healthcare professionals entering information into your
chiropractic records relating to your chiropractic care and treatment. We may share information
about you including chiropractic treatment, x-rays, prescriptions and requests for lab work.

Payment. We may need to disclose information about the treatment, procedures or chiropractic
care our practice provided to you in order to bill and receive payment for services we provided.
We may share this information with you, an insurance company or any third party responsible for
payment. We may also need to disclose personal health information about you with your health
plan and/or referring physician in order to obtain prior authorization for treatment, to determine
whether payment for chiropractic care is covered by your plan or to facilitate payment of a
referring physician.

Chiropractic Operations. In order to help us run our practice more efficiently and provide better
patient care, we may use and disclose your personal health information to Business Associates
who need to use or disclose your information to provide a service for our medical practice, such
as our chiropractic billing company or chiropractic software vendors who provide assistance with
data management on our behalf or vendors who provide orthopedic supports and compression

Public Health Activities/Risks. Your chiropractic information may be disclosed to a public health
authority that is authorized by law to collect or receive such information for public health activities.
Certain disclosures may be made for public health activities in the following circumstances:

1) to prevent or control disease, injury or disability;
2) to report of births or deaths;
3) to report child abuse or neglect;
4) to report reactions to medications or product defects;
5) to notify individuals of product recalls;
6) to notify a person who may have been exposed to a communicable disease or at risk
of contracting or spreading a disease or condition;
7) if our practice reasonably believes a person is the victim of abuse, neglect, or domestic
violence, we may disclose personal health information to the appropriate authority. We
will only make this disclosure if you agree to the disclosure or we are required or authorized to do
so by law without your permission.

Appointment Reminders or Treatment Alternatives. Our practice may use and disclose
chiropractic information about you to provide you with reminders that you are due for care or you
have an upcoming appointment. We may also wish to provide you with information on treatment
alternatives or other health related benefits that may be of interest to you. We may contact you by
phone, text, fax or e-mail. We will make every effort to protect your privacy when leaving a
message for you and try to reveal as little confidential information as possible (e.g., when leaving
a message on your answering machine that may be heard by others).

To Avert Serious Threat to Health or Safety. If our practice believes, in good faith, that a use or
disclosure of your medical information is necessary to prevent or lessen a serious and imminent
threat to the health or safety of a person or the public, we may disclose your chiropractic

Worker's Compensation. We may release medical information about you for work-related illness
or injury for workers' compensation or other related programs.
Health Oversight Activities. Your personal health information may be disclosed to federal, state or
local authorities as part of an investigation or government activity authorized by law. This may
include audits, civil, administrative or criminal investigations, inspections, licensure or disciplinary
actions or other activities necessary for the oversight of the health care system, government
benefit programs and compliance with government regulatory programs or civil rights laws.

Law Enforcement. We may disclose your personal health information to law enforcement
individuals if we are required to do so by law. We may also disclose medical information about
you in compliance with a court order, warrant or subpoena or summons issued by the court. We
will make best efforts to contact you about these types of requests so that you can obtain an
order restricting or prohibiting disclosure of the information requested. We may also use such
information to defend ourselves in actions or threatened actions that may be brought against our

Other uses and disclosures will be made only with your written authorization and you may revoke
your authorization at any time.

Patient Rights
You have the following rights with respect to your personal health information:

Right to Receive Personal Health Information Confidentially. You have the right to receive
confidential communications of your personal health information (treatment by a chiropractor,
acupuncturist, functional medicine doctor) by alternate means or at alternate locations. For
example, if you would like for us only to communicate with you at home, and never at your
workplace or to send information to you on your workplace e-mail, you may request this of our
practice. You must make this request in writing but do not need to disclose the reason for your
request. We will attempt to accommodate all reasonable requests. Please be specific as to how
or where you wish us to communicate with you.

Right to Inspect and Copy. You have the right to inspect and copy your chiropractic, acupuncture
or functional medicine record that has been created to treat you and is used to make decisions
about your care. This includes chiropractic, acupuncture, functional medicine and billing records.
Records related to your care may also be disclosed to an authorized person such as a parent or
guardian upon proper proof of a legitimate legal relationship. You must submit your request in
writing to inspect and copy your records. If you would like to copy your records, our practice may
charge you fees for the cost of copying records, mail or other minimal costs associated with your
request. See Appendix A.

Right to Amend. If you think there is information in your record that may be inaccurate or
incomplete, you have the right to request an amendment or clarification of information in your
record. Your request to make an amendment to your record must include the following and may
be refused if the following elements are not met:
1) Submit your request in writing
2) Describe what you would like the amendment to say and your reasoning for why the change
should be made
3) The amendment must be dated, signed by you and notarized
Please note that we will not change information created by third parties, if the information is not
part of the medical information kept by our practice or we believe the information you provided to
us is inaccurate or incomplete. We reserve the right to deny your request if we have reason to
believe the information is accurate. See Appendix B.

Right to Restrict Uses and Disclosures. You have the right to request restrictions on how our
practice makes certain uses and disclosures of your chiropractic health information for treatment,
payment or healthcare operations. You may restrict how much information we may provide to
family members regarding your treatment or payment for your care. You may also restrict certain
types of marketing materials related to your care or treatment. We are not required to agree to
your request or we may not be able to comply with your request, but we will do all that we can to
accommodate your request. If we agree to your request, we must comply. However, if the
information is required to provide emergency treatment to you, we will not comply. Your request
must be in writing and include the following:
1) what information you would like to limit
2) whether you want to limit our use, or disclosure or both
3) to whom you want the limits to apply (e.g., disclosures to parents, children, spouse,
etc.) See Appendix C.

Right to an Accounting of Uses and Disclosures. You have the right to receive an accounting of
the disclosures of your chiropractic health information that our practice makes for purposes other
than treatment, payment or healthcare operations. All requests must be submitted in writing. All
requests must state a time period not longer than six (6) years back. You must state whether you
would like the accounting in electronic or paper form. One request in a twelve-month period will
be provided to you at no charge. We may charge you a fee for all additional requests within a
twelve-month period. We will notify you as to the cost of fulfilling your additional request and allow
you the opportunity to modify it before fees are due. See Appendix D. All requests should be
submitted to the reception desk for appropriate processing.

Right to Copy of Notice. You have the right to obtain a copy of our notice of privacy practices
upon request at any time. Please call us at 515-233-2263 for a copy or ask for a copy at the
reception desk. [Please Note: You may provide the option to receive the notice via e-mail, but you
can inform your patients they are still entitled to a paper copy if they choose this option].

Changes to this Notice. Our practice is required to abide by the terms of this notice, which is
currently in effect. We reserve the right to change the terms of this notice and to make the new
notice provisions effective for all personal chiropractic information we already have about you and
may obtain in the future. If we change our notice, we will post notice of this change thirty (30)
days prior to making the change effective.

Practice Contact. If you would like more information about this notice, please contact Dr. Rod
Rebarcak, Chiropractor-Owner, at 515-233-2263. If you have any complaints regarding our
privacy practices, please address your complaint to Dr. Rebarcak in writing and follow the
designated complaint process below.

Complaints. If you believe your privacy rights may have been violated or you become aware of a
privacy concern you would like to report to our practice, please follow this complaint process:
1. Send a written letter to the practice contact named above, including the following information:
a. Name and Address
b. Social Security Number or Patient Identification Number
c. Detailed description of the circumstances surrounding your complaint including dates,
times and any relevant information to help us understand your complaint.
d. Contact information
e. Signature and Date
2. Please allow fourteen (14) business days for an answer from our practice regarding your
3. If you are not satisfied with our response to your complaint, you may notify the Secretary of the
Department of Health and Human Services.
Please note, all concerns or complaints regarding your personal health information are important
to our practice. There will be no retaliation against you for filing a complaint with our office.

Additional Privacy Protections. Our practice is committed to protecting your privacy and for the
proper use and disclosures of your personal health information. For example, if you treat patients
with particularly sensitive conditions, even though the law allows you to disclose the information
for various reasons, you will not do so unless required by law.

Electronic Notice. We are also required to prominently post our Notice of Privacy Practices on our
chiropractic Website.