Visit our Location
69 Center Road, Essex, VT
Give us a Call
(802) 662-1047

Notice of Privacy for Protected Health Information

This notice Describes how Chiropractic and Medical information about you may be used and disclosed and how you can get access to this information.  Please review carefully.

Use and Disclosures

Here are some examples of how we might have to use or disclose your health care information:

  1. Your chiropractor or a staff member may have to disclose your health information, including all of your clinical records, to another health care provider or a hospital if it is necessary to refer you to them for diagnosis, assessment, or treatment of your health.  
  2. Our insurance and billing staff may have to disclose your examination and treatment records and your billing records to another party, such as an insurance carrier, and HMO, a PPO, or your employer, if they are potentially responsible for the payment of your services.
  3. Your chiropractor and members of the staff may need to use your health information, examination and treatment records and your billing records for quality control purposes or for other administrative purposes to efficiently and effectively run our practice.
  4. Your chiropractor and members of the practice staff may need to use your name, address, phone number, and your clinical records to contact you to provide appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you.  164.520(b)(I)(iii)(A).  If you are not at home to receive the appointment reminder, a message will be left on your machine.

You have the right to refuse to give us authorization to contact you to provide appointment reminders, information about treatment alternatives, or other health related information.  If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.

Our Privacy Pledge

We have and always will respect your privacy.  Other than the uses and disclosures we described above, we will not sell or provide any of your health information to any outside marketing organization.

Permitted Uses and Disclosures without Your Consent or Authorization

Under Federal Law, we are also permitted or required to disclose your health information without your consent or authorization in the following circumstances:

  1. If we are providing health care services to you based on the orders of another health care provider.
  2. If we provide health care services to you as an inmate.
  3. If we provide health care services to you in an emergency.
  4. If we are required by law to treat you and were unable to obtain your consent after attempting to do so.
  5. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.

Other than the circumstances described in the preceding five examples and noted in the uses and disclosures section above, other use or disclosure of your health information will only be made with your written authorization.

Your Right to Revoke Your Authorization

You may revoke your authorization to us at any time; however, your revocation must be in writing.  There are two circumstances under which we will not be able to honor your revocation request:

  1. If we have already released your health information before we receive request to revoke your authorization 164.508(b)(5)(i)
  2. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.  If you wish to revoke your authorization, please write to us at our office address, c/o Billing Department.

Your Right to Limit Uses or Disclosures

If there are health care providers, hospitals, employers, insurers, or other individuals or organizations to whom you do not want us to disclose your health information, please let us know in writing to what individuals or organizations you do not want us to disclose your health care information.  We are not required to agree to your restrictions.  However, if we agree with your restrictions, the restriction is binding on us.  If we do not agree to your restrictions, you may drop your request or you are free to seek care from another health care provider.

Your Right to Receive Confidential Communication Regarding Your Health Information 

We normally provide information about your health to you in person at the time you receive services.  We may also mail you information regarding your health or about the status of your account.  We will do our best to accommodate any reasonable request if you would like to receive information about health or the services that we provided at a place other than your home, or, if you would like information in a different form.  To help us respond to your needs, please make any request in writing.

Your Right to Inspect and Copy Your Health Information

You have the right to request that we give you an account of the disclosures we have made of your health information for the last six years before the date of your request.  The accounting will include all disclosures except these disclosures:

  • Required for your treatment, to obtain payment for your services, or to run our practice
  • Made to you or to individuals involved in your care
  • Necessary to maintain a director of the individuals in our facility
  • For national security or intelligence purposes, as required by law
  • Made to correction officers or law enforcement officers, as required by law
  • That were made prior to the effective date of the HIPPA privacy law
  • We will provide the first accounting within a 12 month period without charge.  There is a fee for any additional requests during the next 12 months.  When you make your request, we will tell you the amount of the fee, and you will have the opportunity to withdraw or modify your request.  There is a $20 fee on all returned EFTs or paper checks, and a $5 fee on returned Visa/MasterCard/Discover transactions.  Should you require a copy of your X-rays, there is a $50 copy fee and we require 5 business days to complete your request.

Your Right to Obtain a Paper Copy of This Notice

If you have agreed to the privacy notices by email, you may request a paper copy of this notice at any time.

Our Duties

We are required by law to maintain the privacy of your health information.  We are also required to provide you with this notice of our legal duties and our privacy practices with respect to your health information.

We must abide by the terms of this notice while it is in effect.  However, we reserve the right to change the terms of our privacy notices.  If we make a change to the terms of our privacy agreement, we will notify you in writing when you come in for treatment or by mail.  If we make a change in our privacy terms, the change will apply for all your health information in our files.


Information that we use or disclose may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by federal privacy rules.

Your Right To Complain

You may complain to us or to the Secretary of Health and Human Services if you feel that we have violated your privacy rights.  We respect your right to file a complaint, and will not take any action against you if you file a complaint.  While you may make an oral complaint at any time, written comments should be addressed to Dr. Tilyr Dunklow at our office address shown at the top of the opposite page.

To Contact Us

If you would like further information about our privacy policies and practices, please contact Summit Chiropractic Center at 69 Center Rd, Essex Junction, VT  05452 or by phone at 802-662-1047.  This notice is effective as of May 01, 2015, or the date of your signed acknowledgement of receipt of this notice.  This notice will expire six years after the date upon which the record was created.