Important Notice

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices (“Notice”) explains how Elite Performance Institute may use and disclose your protected health information (“PHI”), and explains your rights and our legal duties with respect to your PHI. “PHI” is information about you that may identify you and relates to your past, present, or future physical or mental health or condition and related healthcare services.

Privacy Officer: Dr. Brian Damhoff, DC. To exercise any privacy rights or to file a complaint, call 331-472-4326 and ask for the Privacy Officer.

1) Who We Are

This Notice applies to Elite Performance Institute and our workforce members, including our doctors and staff. Our treating clinicians include Dr. Brian Damhoff, DC and Dr. Maxwell Warren, DC.

2) Our Legal Duties

We are required by law to:

• Maintain the privacy and security of your PHI.
• Provide you with this Notice of our legal duties and privacy practices.
• Follow the terms of this Notice currently in effect.
• Notify you following a breach of unsecured PHI as required by law.

We reserve the right to change this Notice, and the changes will apply to all PHI we maintain. The updated Notice will be available upon request and in our office (and on our website if we post it there).

3) How We May Use and Disclose PHI

We may use and disclose your PHI for the following purposes as permitted by law. In many situations, we apply the “minimum necessary” standard (for example, for certain payment and healthcare operations activities), meaning we limit what we use, disclose, or request to what is needed to accomplish the intended purpose. The minimum necessary standard does not generally apply to disclosures for treatment.

A. Treatment

We may use and disclose PHI to provide, coordinate, or manage your care. This may include sharing PHI with other healthcare providers you identify or who are involved in your care.

B. Payment

We may use and disclose PHI to bill and obtain payment for services, including eligibility/coverage checks, claim submission, prior authorization, medical necessity review, and utilization review.

C. Healthcare Operations

We may use and disclose PHI to support practice operations, including quality improvement, staff training, credentialing, audits, legal services, business planning, and general administrative activities.

D. Business Associates

We may disclose PHI to third parties (“business associates”) that perform services for us (for example, billing, EHR services, IT support). Business associates are required to protect PHI under written agreements.

E. Appointment Reminders and Care-Related Communications

We may contact you regarding appointment reminders, scheduling changes, missed appointments, and care-related information by phone, voicemail, text message, email, or mail unless you tell us you prefer a different method (for example, “no voicemail”).

F. Individuals Involved in Your Care

Unless you object, we may disclose relevant PHI to a family member, friend, or other person you identify who is involved in your care or payment for your care. If you are not able to agree or object, we may use professional judgment to determine whether disclosure is in your best interest.

G. Disclosures Required or Permitted by Law (Public Interest Activities)

We may disclose PHI as allowed or required by law, including for:

• Public health activities (such as reporting certain conditions as required)
• Reporting abuse, neglect, or domestic violence as required or permitted by law
• Health oversight activities (audits, investigations, inspections)
• Legal proceedings (court orders and other lawful process as permitted)
• Law enforcement purposes as permitted by law
• Coroners/medical examiners and funeral directors
• Organ/tissue donation
• Research as permitted under applicable protections
• To prevent or reduce a serious threat to health or safety as permitted by law
• Workers’ compensation
• Military, national security, and other specialized government functions
• Correctional institutions or lawful custody situations as permitted by law

We may also make disclosures that are incidental to an otherwise permitted use or disclosure (for example, a patient may be overheard when speaking with staff at the front desk). We use reasonable safeguards to limit incidental disclosures.

4) Uses and Disclosures That Require Your Written Authorization

We will obtain your written authorization for uses and disclosures not described in this Notice or not otherwise permitted by law. In addition, we will obtain your written authorization in most cases for:

• Marketing communications where HIPAA requires authorization
• Sale of PHI (we do not sell PHI)
• Psychotherapy notes (generally not applicable to chiropractic care, but included for completeness)

You may revoke an authorization at any time in writing, except to the extent we have already relied on it.

5) Special Protections for Certain Substance Use Disorder Records (42 CFR Part 2)

In some situations, our office may receive records from a Substance Use Disorder (SUD) treatment program that are protected by federal confidentiality rules (42 CFR Part 2). If we receive Part 2–protected records, we will maintain and disclose them only as permitted by 42 CFR Part 2 and other applicable law. Depending on the circumstances, disclosure may require specific consent or a qualifying court order, and additional redisclosure restrictions may apply.

If you have questions about how Part 2 protections apply to information in your file, please contact the Privacy Officer by calling 331-472-4326.

6) Your Rights

A. Right to Inspect and Obtain a Copy

You may request to inspect or receive a copy of your medical record and other PHI we maintain about you. We will respond within the time required by law. We may charge a reasonable, cost-based fee for copies (including electronic copies) as permitted by law.

B. Right to Request an Amendment

You may request that we amend PHI you believe is incorrect or incomplete. We may deny your request in certain circumstances and will provide a written explanation if we deny it.

C. Right to Request Confidential Communications

You may request that we contact you in a specific way or at a specific location (for example, “text only,” “no voicemail,” or a different mailing address). We will accommodate reasonable requests.

D. Right to Request Restrictions

You may request restrictions on certain uses and disclosures of your PHI for treatment, payment, or healthcare operations. We are not required to agree to every request.

Restriction you can require: If you pay for a service in full out-of-pocket, you may request that we not disclose information about that service to your health plan for payment or healthcare operations. We will honor that request unless a law requires disclosure.

E. Right to an Accounting of Certain Disclosures

You may request an accounting of certain disclosures made in the prior six (6) years, excluding disclosures for treatment, payment, healthcare operations, and certain other exceptions. One accounting per 12-month period may be provided at no charge; additional requests may incur a reasonable fee.

F. Right to a Paper Copy of This Notice

You may request a paper copy of this Notice at any time, even if you have agreed to receive it electronically.

G. Right to Choose Someone to Act for You

If you have a legal guardian, healthcare power of attorney, or other valid legal authority, that person may exercise your rights and make choices about your PHI after we verify their authority.

7) Questions and Complaints

If you have questions about this Notice, would like to exercise your rights, or believe your privacy rights have been violated, please call 331-472-4326 and ask for the Privacy Officer.

You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint.

8) Changes to This Notice

We reserve the right to change this Notice at any time, and any changes will apply to all PHI we maintain. The updated Notice will be available upon request and in our office (and on our website if we post it there).

9) State Law

To the extent Illinois law provides greater privacy protections than federal law, we will follow the stricter requirement.