Privacy Policy

Sarpy Chiropractic

Rodney White D.C.




This Practice is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about your health condition and the care and treatment you receive from the Practice. The creation of a record detailing the care and services you receive helps this office to provide you with quality health care. This Notice details how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI.


  1. The Practice may use and/or disclose your PHI for the purposes of:
    1. Treatment-
  1. Payment-
  1. Health Care Operations -

2. The Practice may also use and/or disclose your PHI in the following instances:

  1. Business Associate-

  1. Personal Representative-

  1. Emergency Situations-
    1. for the purpose of obtaining or rendering emergency treatment to your provided that the Practice attempts to obtain your acknowledgement of our Privacy Notice as soon as possible; or

  1. Communication Barriers-

  1. Public Health Activities-

  1. Abuse, Neglect or Domestic Violence-

  1. Health Oversight Activities-

  1. Judicial and Administrative Proceeding-

  1. Law Enforcement Purposes-

  1. Coroner or Medical Examiner-

  1. Organ, Eye or Tissue Donation- If you are an organ donor, the Practice may disclose your PHI to the entity to whom you have agreed to donate your organs

  1. Research-

  1. Avert a Threat to Health or Safety-

  1. Specialized Government Functions-

  1. Workers’ Compensations-

  1. National Security and Intelligence Activities-

  1. Military and Veterans-

  1. Marketing Purposes-

  1. Sale of your PHI-

  1. Fundraising Uses-
  2. Disclosure Following Death-


The Practice may, from time to time, contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. The following appointment reminders are used by the practice: a) a postcard mailed to you at the address provided by you: b) telephoning your home and leaving a message on your answering machine or with the individual answering the phone: c) sending a text message to the cell phone number provided by you: and d) sending an email to the email address provided by you.


The Practice may, from time to time, send out letter or newsletter for the purpose of providing health related information, information on office activities, changes in office procedure, or such information as they may find necessary to convey to patients of the Practice. This will be done in a newsletter form or a letter enclosed within an envelope and mailed directly to the patient or done by email.


The Practice may, from time to time, transmit information about you to insurers, other health care professionals and providers, and appropriate government agencies utilizing facsimile transmissions.


The Practice may in the future maintain a directory of and sign-in log for individuals seeking care and treatment in the office. Directory and sign-in log are located in a position where staff can readily see who is seeking care in the office, as well as the individual’s location within the Practice’s office. This information may be seen by, and is accessible to, others who are seeking care or services in the Practice’s offices.


The Practice may disclose to your family member, other relative, a close personal friend, or any other person identified by you, your PHI directly relevant to such person’s involvement with your care or the payment for your care. The Practice may also use or disclose your PHI to notify or assist in the notification (including identifying or locating) condition or death. However, in both cases, the following conditions will apply:

1) If you are present at or prior to the use or disclosure of your PHI, the Practice may use or disclose your PHI if you agree or if the Practice can reasonably infer form the circumstance, based on the exercise of its professional judgment, that you do not object to the use or disclosure.

2)If you are not present, the Practice will, in the exercise of professional judgment, determine whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is directly relevant to the person’s involvement with your care.


Uses and/or disclosures, other than those described above, will be made only with your written Authorization.


1. You have the right to:

A) Revoke any Authorization, in writing, at any time. To request a revocation, you must

submit a written request to the Practice’s Privacy Officer.

B) Request restrictions on certain use and/ or disclosure of your PHI as provided by law. However, the Practice is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to the Practice’s Privacy Officer. In your written request, you must inform the Practice of what information you want to limit, whether you want to limit the Practice’s use or disclosure, or both, and to whom you want the limits to apply. If the Practice agrees with you request, the Practice will comply with your unless the information is needed in order to provide you with emergency treatment.

C) Receive confidential communications or PHI by alternative means or at alternative locations. You must make your request in writing to the Practice’s Privacy Officer. The practice will accommodate all reasonable requests.

D) The patient has the right to restrict disclosure of PHI by the Practice to insurance and health plans if the individual has paid for services completely out of pocket. Such request should be made by the patient, in writing, to the Privacy Officer.

E) Inspect and copy your PHI as provided by law. To insect and copy your PHI, or transmit a copy to another person, you must submit a written request to the Practice’s Privacy Officer. You may request a digital or written copy of your information. The Practice can charge you a fee for the cost of copying, mailing or other supplies associated with your request but such cost shall not exceed the cost of the office to produce the material including the cost of copies, employee time involved etc. The Practice has 30 days following the written request to produce the requested information in the format requested or negotiate an alternative format. In certain situations that are defined by law, the Practice may deny your request, but you will have the right to have the denial reviewed as set forth more fully in the written denial notice.

F) Amend your PHI as provided by law. To request an amendment, you must submit a written request to the Practice’s Privacy Officer. You must provide a reason that supports your request. The Practice may deny your request if it is not I in writing, if you do not provide a reason in support of you request, if the information to be amended was not created by the Practice (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by the Practice, if the information is not part of the information you would be permitted to insect and copy, and/or in the information is accurate and complete. If you disagree with the Practice’s denial, you will have the right to submit a written statement of disagreement.

G) Receive an accounting of disclosures of your PHI as provided by Law. To request an accounting, you must submit a written request to the Practice’s Privacy Officer. The request must state a time periods which may not be longer than six (6) years and may not include dates before April 14, 2003. The request should indicate in what form you want the list (such as paper or electronic copy). The first list you request within a twelve (12) month period will be free, but the Practice may charge you for the cost of providing additional lists. The Practice will notify you of the costs involved and you can decide to withdraw your modify our request before any costs are incurred.

H) Receive a paper copy of the Privacy Notice from the Practice upon request to the Practice’s Privacy Officer.

I) Complain to the Practice or to the Secretary of HHS if you believe your privacy rights have been violated. To file a complaint with the Practice, our must contact the Practice’s Privacy Officer. All complaints must be in writing.

J) To obtain more information on, or have our questions about your rights answered, you may contact the Practice’s Privacy Officer, Melanie White at Sarpy Chiropractic, 10701 S 72nd st, Ste 120, Papillion, NE, 68046 or by phone at 402-593-9930 or by email at [email protected], listing Privacy Policy in the title of your email so it can be identified as a Privacy Policy related question.


1. The Practice

A) Is required by federal law to maintain of your PHI and to provide you with this Privacy Notice detailing the Practice’s legal duties and privacy practices with respect to your PHI.

B) Under the Privacy rule may be required by state law to grant greater access or maintain greater restrictions on the use or release of your PHI then that which is provided for under federal law.

C) Is required to abide by the terms of this Privacy Notice.

D) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for your entire protected health information that it maintains.

E) Will distribute any revised Privacy Notice to you prior to implementation.

F) Will not retaliate against you for filing a complaint.

G) The practice is required to notify you, in writing or by email, of a breach or incidence of unsecured PHI if such breach has led to, or may lead to, your PHI being compromised.


This Notice is in effect as of September 22, 2013.

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