NOTICE OF PRIVACY PRACTICES
REJUVENATION Chiropractic + Sports Rehab
Wilmington, North Carolina
Effective Date: September 9, 2026
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
REJUVENATION Chiropractic + Sports Rehab (“REJUVENATION,” “we,” “our,” or “the Practice”) is committed to protecting the privacy and security of your health information.
We are required by law to maintain the privacy and security of your Protected Health Information (“PHI”), provide you with this Notice explaining our legal duties and privacy practices, follow the terms of the Notice currently in effect, and notify you following a breach of unsecured PHI when required by law.
How We May Use and Disclose Your Health Information
We may use or disclose your health information for the following purposes without obtaining a separate written authorization when permitted by law.
Treatment
We may use and disclose your health information to provide, coordinate, and manage your healthcare.
For example, we may share relevant information with another healthcare professional involved in your care, such as a physician, physical therapist, athletic trainer, imaging facility, specialist, or other healthcare provider.
Payment
We may use and disclose your health information to bill and collect payment for services provided to you.
This may include providing necessary information to health plans, insurance companies, attorneys, billing services, or other responsible payers when legally permitted.
Healthcare Operations
We may use and disclose your health information for activities necessary to operate our practice. These activities may include:
Quality assessment and improvement
Staff training
Credentialing
Compliance activities
Auditing
Business planning
Administrative functions
Legal and professional consultation
Electronic health record and practice-management services
We utilize electronic systems, including ChiroTouch/CT Cloud, to assist with patient records and practice operations.
Appointment Reminders and Communications
We may use your contact information to communicate with you regarding appointments, scheduling, treatment, billing, follow-up care, and other healthcare-related matters.
Communications may occur by telephone, voicemail, text message, email, patient portal, or other methods you have authorized or that are otherwise permitted by law.
You may request that we communicate with you in a particular way or at a particular location.
Other Uses and Disclosures Permitted or Required by Law
We may use or disclose your health information without written authorization in certain circumstances permitted or required by law, including:
When required by federal, state, or local law
Public health activities
Reporting suspected abuse, neglect, or domestic violence when required or authorized by law
Health oversight activities
Judicial and administrative proceedings
Certain law-enforcement purposes
Workers' compensation matters
Preventing or reducing a serious and imminent threat to health or safety
Certain government functions
Coroners, medical examiners, and funeral directors when applicable
Organ and tissue donation when applicable
Research when permitted by law
Other circumstances specifically permitted or required by applicable law
Only the information reasonably necessary for the permitted purpose will be disclosed when the minimum-necessary standard applies.
Personal Injury and Legal Matters
If your care involves a motor vehicle collision, personal injury matter, workers' compensation claim, or other legal matter, we may disclose relevant health and billing information when permitted by law.
This may include disclosures to attorneys, insurers, claims representatives, or other parties when you have provided appropriate authorization or when disclosure is otherwise permitted or required by law.
Uses Requiring Your Written Authorization
Uses or disclosures of your PHI that are not otherwise permitted or required by law generally require your written authorization.
Certain uses and disclosures, including certain marketing activities, the sale of PHI, psychotherapy notes when applicable, and other specially protected information, may require specific authorization.
If you provide written authorization, you may revoke that authorization in writing at any time, except to the extent that we have already taken action in reliance on it or as otherwise provided by law.
We will not sell your PHI without authorization where authorization is required by law.
Your Rights Regarding Your Health Information
You have important rights concerning your health information.
Obtain a Copy of Your Medical Record
You may request to inspect or obtain a paper or electronic copy of your medical record and other health information we maintain about you.
We will generally provide access within the timeframe required by law. We may charge a reasonable, cost-based fee when permitted by law.
In limited circumstances, we may deny access to certain information. If access is denied, you may have a right to request review of that decision.
Ask Us to Correct Your Medical Record
If you believe information in your record is incorrect or incomplete, you may ask us to amend it.
We may deny the request under circumstances permitted by law. If we deny your request, we will provide an explanation as required.
Request Confidential Communications
You may ask us to contact you in a specific manner or at a specific location.
For example, you may request that we contact you only at a particular telephone number or email address.
We will accommodate reasonable requests as required by law.
Request Restrictions
You may ask us not to use or disclose certain health information for treatment, payment, or healthcare operations.
We are generally not required to agree to all requested restrictions.
However, if you pay for a healthcare service or item in full out of pocket and ask us not to disclose information about that service or item to your health plan for payment or healthcare operations, we will honor that request when required by law.
Receive an Accounting of Disclosures
You may request a list, or “accounting,” of certain disclosures we have made of your health information.
The accounting does not include every type of disclosure, such as many disclosures made for treatment, payment, and healthcare operations.
We will provide an accounting in accordance with applicable law.
Receive a 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.
Choose Someone to Act for You
If you have given someone medical power of attorney or another person is legally authorized to act on your behalf, that individual may exercise your rights and make choices concerning your health information as permitted by law.
We may verify that the individual has appropriate authority before taking action.
Your Choices
For certain health information, you may tell us your preferences about what we share.
Depending on the circumstances, you may have choices regarding sharing information with family members, friends, caregivers, or other individuals involved in your care or payment for your care.
If you are unable to communicate your preference, we may share information when legally permitted and when we determine that doing so is in your best interest.
Electronic Health Information
We may maintain your records electronically and use electronic systems to communicate, store, retrieve, and manage health information.
We implement reasonable administrative, physical, and technical safeguards designed to protect electronic PHI.
No electronic communication method is completely risk-free. When available, patients are encouraged to use secure patient communication methods for sensitive health information.
Our Responsibilities
REJUVENATION Chiropractic + Sports Rehab is required to:
Maintain the privacy and security of your PHI
Follow applicable federal and state privacy laws
Provide you with this Notice of our legal duties and privacy practices
Follow the terms of the Notice currently in effect
Notify affected individuals when a breach of unsecured PHI requires notification
Respect the privacy rights described in this Notice
If state or other applicable law provides greater privacy protection than federal law, we will comply with the more protective requirement when applicable.
Changes to This Notice
We reserve the right to change this Notice and our privacy practices.
Changes may apply to information we already maintain as well as information we receive in the future, as permitted by law.
The current version of this Notice will be available through our practice and, when applicable, on our website.
Questions or Complaints
If you believe your privacy rights have been violated, have questions about this Notice, or would like to exercise one of your privacy rights, please contact:
Privacy Officer
Dr. Jasmine Brewster Piper, DC, DACBSP®
REJUVENATION Chiropractic + Sports Rehab
Wilmington, North Carolina
Phone: 910 685 4481
Email: info@rejuvenationchiro.com
Website: www.rejuvenationchiro.com
You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights.
You will not be retaliated against or denied treatment for filing a privacy complaint.
Acknowledgment of Receipt
I acknowledge that I have been provided with or given access to REJUVENATION Chiropractic + Sports Rehab's Notice of Privacy Practices.
Patient Name: ______________________________________
Patient/Representative Signature: ______________________________
Date: __________________
If signed by a personal representative:
Representative Name: ______________________________________
Relationship/Authority: _____________________________________