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The Spine Chiropractic 

HIPAA Notice of Privacy Practices


Effective Date: January 1, 2023





This Notice of Privacy Practices (the “Notice”) describes The Spine Chiropractic’s practices and those of Company employees, staff, volunteers, and other personnel who are involved in your care. The Company and these individuals will follow the terms of this Notice, and may use or disclose medical information about you to carry out treatment, payment or health care operations, or for other purposes as permitted or required by law. This Notice describes your rights to access and control medical information about you, including information that may identify you and that relates to your past, present, or future physical, medical, or mental condition and medical care and related health care services.



The Company understands that medical information about you and your health is personal. The Company is committed to protecting medical information about you. In order to provide you with quality care and to comply with certain state and federal legal requirements, the Company creates a record of the services you receive at the Company. This Notice applies to all of the records of your care generated by the Company. This Notice will tell you about the ways in which the Company may use and disclose medical information about you. It also describes your rights and certain obligations the Company has regarding the use and disclosure of medical information. The Company is required by law to: (1) Make sure that medical information that identifies you is kept private; (2) Give you this Notice of its legal duties and privacy practices concerning medical information about you; (3) Follow the terms of the Notice that are currently in effect, and (4) Notify you in case there is an unauthorized use or disclosure of your unsecured medical information.



The following categories describe different ways that The Spine Chiropractic may use or disclose protected medical information. For each category of uses and disclosures, an explanation will be given.  Not every use or disclosure in a category will be listed. However, all the ways The Spine Chiropractic is permitted to use and disclose information will fall within one of the following categories. 

For Payment. The Spine Chiropractic may use and disclose medical information about you so that payment for treatment and services received may be paid.

For Individuals and/or Family Members Involved in your care.  Unless you object, The Spine Chiropractic may disclose medical information about you to a member of your family, a relative, close friend or any other person that you identify involved in your care.  The Spine Chiropractic may also tell your family or friends, personal representative, or any other person who is responsible for your care, of your location, general condition or death, unless you object.

Emergencies.  The Spine Chiropractic may disclose medical information about you to a public or private entity assisting in disaster relief such as earthquakes so that your family can be notified about your condition, status, or location.  You may object to this disclosure with a written request.  If you are not available or are unable to to agree or object, or in an emergency circumstance, The Spine Chiropractic will use its professional judgement to decide whether this disclosure is in your best interest.

For Health Care Operations including Insurance Contractual Obligations. The Spine Chiropractic may use and disclose medical information about you to carry out activities that are necessary for all operations.  The uses and disclosures are made for quality of care, compliance activities, administrative purposes, contractual obligations, grievances or lawsuits.  The Spine Chiropractic may use medical information to review treatment and services provided to evaluate performance in care and any associations to improve quality of treatment, including any insurance contractual obligations.

Workers Compensation. The Spine Chiropractic may release medical information about you for workers’ compensation or similar programs regarding benefits for work-related injuries or illness.

Insurance Carriers.  The Spine Chiropractic may release medical information provided about you to any related insurance carrier.  Such information to obtain benefits, eligibility, pre-authorization, deductibles, claims, and any information necessary related to of interest, services rendered or payment of services. The Spine Chiropractic may report and give reason of treatment and services to insurance carrier including any information to maintain within contractual obligations of The Spine Chiropractic and insurance carrier. 

For Health Oversight Activities. The Spine Chiropractic may disclose medical information about you to a health oversight agency for activities authorized by law.

Disclosure to Law Enforcement. The Spine Chiropractic may release medical information if asked to do so by law enforcement and as authorized or required by law. Such cases include: 1. To identify or locate a suspect, fugitive, material witness, or missing person. 2. About a suspected victim of crime even if unable to obtain the persons agreement. 3 About a death that may be suspected to be the result of criminal conduct. 4. Criminal Conduct at The Spine Chiropractic. 5. In case of medical emergency, to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime. 



Disclosure for threats to health and safety. In certain circumstances, the company may be required to disclose medical information to avert a serious threat to your health and safety or the health and safety of any person related to The Spine Chiropractic as required by law enforcement.  The use or disclosure will be made in compliance with the law and will be limited to relevant requirements of the law.

For Specialized government functions. The Spine Chiropractic may disclose medical information about you to authorized federal officials for intelligence, counter intelligence, and other national security activities.  

For public health activities. The Spine Chiropractic may disclose medical information about you for public health activities. This includes 1. The prevent or control disease, injury, or disability. 2 To report deaths. 3. To report abuse or neglect of children, elders, and dependent adults. 4. To report reactions to medications or problems with products. 5. To notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease of condition.  

Decedents. The Spine Chiropractic may release medical information about you to a coroner,  medical examiner and funeral directors. Information to any individual known to the company as a family member, closer personal family friend,  or any other person identified, who is involved in your care or the payment for your care prior to death, unless indicated otherwise.  

For lawsuits and Disputes. The Spine Chiropractic may disclose medical information about you in response to a court or administrative order, subpoena, discovery request, or other lawful purposes.  

Marketing. The Spine Chiropractic will not release your medical information for marketing purposes without written or verbal authorization from you.

Sale of medical information. The Spine Chiropractic will not sell your medical information without an authorization from you.



The Company reserves the right to change the terms of this Notice at any time. The Company reserves the right to make the revised or changed notice effective for medical information the Company already has about you as well as any information the Company receives in the future. The Company will post a copy of the current Notice. The Notice will contain an effective date.



If you have any questions or believe that your privacy rights have been violated, you may contact The Spine Chiropractic’s HIPAA Privacy Officer in person or mail a written summary of your concern to:

ATTN: Privacy Officer

The Spine Chiropractic

610 E. Francis St. #170

Ontario CA 91761

You may also file a complaint with the Department of Health and Human Services.

    1. Electronically: Visit  to file a complaint electronically via the OCR Complaint Portal.

    2. Writing: Submit a written complaint and send to:

Centralized Case Management Operations

U.S. Department of Health and Human Services

200 Independence Avenue, S.W.

Room 509F HHH Bldg.

Washington, D.C. 20201

Toll-free: (800) 368-1019

TDD toll-free: (800) 537-7697


You will not be penalized or retaliated against for filing a complaint.



Other uses and disclosures of medical information not covered by this Notice or the laws that apply to use will be made only with your written permission. If you provide the Company permission to use or disclose medical information about you, you may revoke that permission in writing at any time. If you revoke your permission the Company will stop any further use or disclosure of your medical information for the purposes covered by your written authorization, except if the Company has already acted in reliance on your permission. You understand that the Company is unable to take back any disclosure the Company has already made with your permission and that the Company is required to retain its records of the care that the Company provided to you.

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