This notice will tell you about your rights and our duties with respect to medical information about you. We reserve the right to change our privacy practices and the terms of this notice at any time, provided these changes are permitted by applicable laws. Before any such changes are made in our privacy practices, we will change this notice and make a new notice available to you upon request.

You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notices, please contact us using the information listed at the end of this notice.

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We may use and disclose medical information about you for treatment, payment and health care operations. Examples of these purposes are:

Treatment: We may disclose medical information about you to other doctors, nurse, hospitals and other health providers who become involved in your care.

Payment: We may use and disclose your medical information so that we may obtain payment for services provided to you. For example, we may need to give your insurance company information about the services we provide to you so your insurance company will pay us for those services or reimburse you for amounts you have paid.

Health Care Operations: We may use and disclose your medical information in connection with out health care operations. Health care operations include:

- quality assessment and improvement activities;

- reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities;

- legal services, and auditing, including fraud and abuse detection and compliance;

- business planning and development; and

- business management and general administrative activities, including management activities relating to privacy, customer service, resolution of internal grievances and creating de-identified medical information or a limited data set.

On Your Authorization: You may give us written authorization to use your medical information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your medial information for any reason except those described in this notice.

Persons Involved In Your Care: With your written permission, we may disclose to a family member, friend or other person, medical information about you that is directly relevant to their involvement in your care or payment for your care. We may also use or disclose your mane and location (and with your written permission, general condition) to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person involved in your care. If you have not previously given us written permission for such uses and disclosures and are present, we will provide you with an opportunity to object to such uses or disclosures. We may not disclose confidential medical information in these circumstances without your written permission.

We may also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up medical supplies, x-rays, or other similar forms of information.

Appointment Reminders: We may use and disclose medical information about you to contact you to remind you of an appointment you have with us.

Disaster Relief: We may use or disclose your name and location to a public or private entity authorized by law or by its charter to assist in disaster relief efforts. We may not disclose confidential medical information (except in response to a written request from a government agency) in these circumstances without your written permission.

Health Related Services: We may use your medical information to contact you with information about health-related benefits and services or about treatment alternatives that may be of interest to you. With your written permission, we may disclose your medical information to a business associate to assist us in these activities.

We may use or disclose your medical information to encourage you to purchase or use a product or service by face-to-face communication or to provide you with promotional gifts. We may not make any other uses or disclosures of your confidential medical information for marketing purposes without your written permission.

Public Benefit: We may use your disclose your medical information as authorized by law for the following purposes deemed to be in the public interest or benefit:

- as required by law; including state worker’s compensation laws;

- for public health activities, child abuse reporting, FDA oversight, and to employers regarding work related illness or injury;

- to report child abuse or neglect;

- to health oversight agencies;

- in response to court and administrative orders and other lawful processes;

- to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crime on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person;

- to coroners, medical examiners, ad funeral directors;

- to avert a serious threat to health or safety;

- in connection with certain research activities;

- to the military and to federal officials for lawful intelligence, counter intelligence, and national security activities;

- to correctional institutions regarding inmates.

You may be able to opt out of some of these disclosures to government agencies.

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You have the following rights with respect to medical information that we maintain about you.

Access: with limited exceptions, you have the right to look at or get copies of your medical information. You must make a request in writing to obtain access to your medical information. A form for making an access request can be obtained using the contact information listed at the end of this notice. You may also request access by sending us a letter to the address at the end of this notice.

You may request that we provide copies in a format other than photocopies. If practical we will use the format other than photocopies. If practical, we will us the format you request. If you request copies, we may charge you permissible fees for copies. If you request an alternative format, we will charge a cost-based fee for providing your medical information in that format. If you prefer, we will prepare a summary or an explanation of your medical information, the preparation of which may include a fee.

We will act on your access request within thirty (30) calendar days after we receive your request. If we grant your request, in whole or in part, we will inform you of our acceptance of your request and provide access and copies.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your medical information for purposes, other than treatment, payment, health care operations for which we have written permission, as authorized by you, and for and certain other activities, since April 14, 2003. We will provide you with the date on which we made the disclosure, the name of the person or entity we disclosed your medical information, a description of the medical information we disclosed, the reason for the disclosure, and certain other information.

If you request a disclosure accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Confidential Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. Such requests shall be made in writing. We must accommodate your request if it is reasonable, specifies the alternative means or location, and provides satisfactory explanation how payments will be handled under the alternative means or location you request.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your medical information. We ask that such requests be made in writing, using a form available through the contact person listed at the end of this notice. We are not required to agree to these additional restrictions. Any agreement we may make to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on your behalf.

Amendment: You have the right to ask us to amend medical information about you. You have this right for so long as we maintain the medical information. To request an amendment, you must submit your request in writing, including the amendment desired and a reason in support of that amendment. A form for making a request may b e obtained through the contact person listed at the end of this notice.

We are not required to honor all requests for amendment. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be appended to the information you wanted amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

Electronic Notice: If you receive this notice on our web site or by email, you are entitled to receive this notice in written form. Please contact us using the information listed at the end of this notice to obtain this notice in written form.

If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your medical information or in response to a request you made to amend or restrict the use or disclosure of your medical information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Clinic Contact: Heather Dalton D.C. - Apex Family Chiropractic

Telephone: (262)723-2739

Fax: (262)723-1056

Address: 210 E. O’Connor Drive Suite 105, Elkhorn, WI 53121