SWEET CHIROPRACTIC INC PS
4525 Intelco Loop SE, Lacey, WA 98503 360 455 3272
Notice of Privacy Practice Summary
This summary discloses how health information about you may be used.
Sweet Chiropractic uses health information about you for treatment, to obtain payment for treatment
with your authorization as required (check laws), for administrative purposes and to evaluate the quality
of care that you receive.
Sweet Chiropractic will not disclose your information to others unless you tell us to do so, or unless the
law authorizes or requires us to do so.
Sweet Chiropractic may use your information to provide appointment reminders, information about
treatment alternatives or other health-related issues.
Sweet Chiropractic may disclose your information for public health activities, to funeral directors to
enable them to carry out their activities, for organ and tissue donations, research, health and safety,
governmental function in order to comply with workers compensation laws and regulations. You have a
right to request restriction, report and retain a copy of your health record, request communication of
your information by alternative means at alternative locations, revoke your authorization and request an
account of your health records.
You may confer to the privacy officer and to the Department of Health and Human Services if you
believe your privacy rights have been violated. You will not be retaliated against for filing a complaint.
Sweet Chiropractic must maintain the privacy of protected health information, provide you with notice of
its legal duties and privacy practices with respect to your health information, abide by the terms of the
notice, notify you if it was unable to agree to the requested restriction on how your information is used
or disclosed, accommodate reasonable requests you may make to communicate with health
information by alternative means or by alternative locations and obtain your written authorization to use
or disclose your health information for reasons other than those listed above and permitted under law.
If you have any question or complaints, please contact Jay Sweet, DC at the above location.
Patient Signature Patient Printed Name Date