NOTICE OF PRIVACY PRACTICES

Effective Date: February 16, 2026

Practice Name: Salance Clinic, Inc. DBA Rejuvenate Health and Wellness Centers
Compliance Officer: Dr. Athena Payne, D.C.
Address: 4255 Bryant Irvin Road, Suite 108, Fort Worth, TX 76109
Phone: 817-731-4848
Email: [email protected]

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

OUR COMMITMENT TO YOUR PRIVACY

Rejuvenate Health and Wellness Centers is committed to protecting the privacy of your health information. We are required by law to:

Maintain the privacy of your protected health information (PHI)

Provide you with this Notice of our legal duties and privacy practices

Follow the terms of this Notice currently in effect

Notify you if we are unable to agree to a requested restriction

Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

This Notice applies to all records of your care generated by this practice.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

The following categories describe different ways we use and disclose health information. Not every use or disclosure will be listed. However, all permitted uses and disclosures will fall within one of these categories.

1. FOR TREATMENT

We may use your health information to provide you with chiropractic treatment or services. We may disclose health information about you to doctors, nurses, massage therapists, or other personnel involved in your care.

Example: Information obtained from you during examination or treatment may be recorded in your record and used by clinic personnel to determine the appropriate course of treatment.

2. FOR PAYMENT

We may use and disclose your health information to bill and collect payment for treatment and services provided to you.

Example: We may send information about your diagnosis and treatment plan to your insurance company to obtain payment or prior authorization for treatment.

3. FOR HEALTHCARE OPERATIONS

We may use and disclose your health information for healthcare operations necessary to run our practice and ensure quality care.

Examples include:

Quality assessment and improvement activities

Employee review activities

Training programs including those in which students, trainees, or practitioners learn under supervision

Accreditation, certification, licensing, or credentialing activities

Business planning and development including cost management

Business management and general administrative activities

Business Associates: We may also share your medical information with our "business associates," such as our billing service, that perform administrative services for us. We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your protected health information.

We may also share your information with other health care providers, health care clearinghouses or health plans that have a relationship with you, when they request this information to help them with their quality assessment and improvement activities, their patient-safety activities, their population-based efforts to improve health or reduce health care costs, or their review of competence, qualifications and performance of health care professionals.

4. APPOINTMENT REMINDERS

We may use and disclose your health information to contact you to remind you of scheduled appointments. We may contact you by phone, text message, email, or postcard.

5. SIGN IN SHEET

We may use and disclose medical information about you by having you sign in when you arrive at our office. We may also call out your name when we are ready to see you.

6. TREATMENT ALTERNATIVES AND HEALTH-RELATED BENEFITS

We may use and disclose your health information to inform you about treatment alternatives or health-related benefits and services that may be of interest to you.

SPECIAL PROTECTIONS FOR SENSITIVE INFORMATION

EFFECTIVE FEBRUARY 2026 - IMPORTANT NEW PROTECTIONS

SUBSTANCE ABUSE INFORMATION

Federal law provides special protections for certain types of health information, including information related to:

Substance use disorder treatment

Drug or alcohol addiction

Substance abuse history or dependencies

How We Protect This Information:

Extra Security Measures: We maintain additional safeguards for substance abuse-related information beyond standard protections for other health information.

Legal Requests: We will NOT release substance abuse information in response to: Attorney subpoenas Informal legal requests Standard discovery requests

Court Orders Only: We will ONLY release substance abuse information when presented with: An actual subpoena issued directly by a court (not an attorney) A valid court order that meets federal requirements

Patient Authorization: When you sign an authorization to release your health information to another provider, insurance company, or third party: You will be specifically informed that substance abuse information may be included Any substance abuse information disclosed may be re-disclosed by the recipient to others Once disclosed, substance abuse information may lose its special federal protections You have the right to revoke your authorization at any time in writing

Notice of Disclosure: If we disclose substance abuse information based on your authorization, we will include a written notice to the recipient stating:

"This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2."

REPRODUCTIVE HEALTH INFORMATION

We also provide special protections for information related to reproductive healthcare services. This information will not be disclosed to law enforcement or other parties without your specific written authorization, except as required by law in limited circumstances.

You have the right to request additional restrictions on how we use or disclose reproductive health information.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION

We will obtain your written authorization before using or disclosing your health information for purposes other than treatment, payment, or healthcare operations, except as described below.

You may revoke your authorization in writing at any time, except to the extent that we have already taken action based on your authorization.

USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR AUTHORIZATION OR OPPORTUNITY TO OBJECT

Federal law permits or requires us to use or disclose your health information without your authorization in the following circumstances:

1. When Required by Law

We may disclose health information when required by federal, state, or local law, including court orders that meet legal requirements.

2. Public Health Activities

To prevent or control disease, injury, or disability

To report births and deaths

To report suspected child abuse or neglect

To report suspected elder or dependent adult abuse or neglect

To report domestic violence

To report reactions to medications or problems with products

To notify people of recalls of products they may be using

To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease

To report to the Food and Drug Administration problems with products and reactions to medications

To report disease or infection exposure

Important: When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.

3. Health Oversight Activities

To federal or state agencies that oversee healthcare activities (e.g., audits, investigations, inspections, licensure).

4. Judicial and Administrative Proceedings

In response to a court order, subpoena, discovery request, or other lawful process, but only if efforts have been made to inform you about the request or to obtain a court order protecting the information, or if your objections have been resolved by a court or administrative order (subject to special protections for substance abuse information described above).

We may also disclose information about you in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order.

5. Law Enforcement

Under limited circumstances:

To identify or locate a suspect, fugitive, material witness, or missing person

About a crime victim in limited circumstances

About a death we believe may be the result of criminal conduct

About criminal conduct at our office

In emergency circumstances to report a crime

In compliance with a court order, warrant, grand jury subpoena and other law enforcement purposes

6. Coroners, Medical Examiners, and Funeral Directors

We may disclose health information to coroners, medical examiners, or funeral directors to enable them to carry out their duties.

7. Organ and Tissue Donation

If you are an organ donor, we may release health information to organizations that handle organ procurement or transplantation.

8. Research

Under certain circumstances and with appropriate safeguards, we may use and disclose health information for research purposes.

9. To Avert a Serious Threat to Health or Safety

We may use and disclose health information when necessary to prevent a serious and imminent threat to your health or safety, or the health or safety of others.

10. Specialized Government Functions

Military and veterans activities (if you are a member of the armed forces)

National security and intelligence activities

Protective services for the President and others

Medical suitability determinations (for U.S. State Department)

Correctional institutions (if you are an inmate)

Workers' compensation programs

11. Victims of Abuse, Neglect, or Domestic Violence

We may disclose health information to government authorities if we reasonably believe you are a victim of abuse, neglect, or domestic violence.

12. Proof of Immunization

We will disclose proof of immunization to a school that is required to have it before admitting a student where you have agreed to the disclosure on behalf of yourself or your dependent.

13. Marketing

Provided we do not receive any payment for making these communications, we may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments, therapies, health care providers or settings of care that may be of interest to you. We may similarly describe products or services provided by this practice and tell you which health plans this practice participates in. We may also encourage you to maintain a healthy lifestyle and get recommended tests, participate in a disease management program, provide you with small gifts, tell you about government sponsored health programs or encourage you to purchase a product or service when we see you, for which we may be paid. Finally, we may receive compensation which covers our cost of reminding you to take and refill your medication, or otherwise communicate about a drug or biologic that is currently prescribed for you.

We will not otherwise use or disclose your medical information for marketing purposes or accept any payment for other marketing communications without your prior written authorization. The authorization will disclose whether we receive any compensation for any marketing activity you authorize, and we will stop any future marketing activity to the extent you revoke that authorization.

14. Sale of Health Information

We will not sell your health information without your prior written authorization. The authorization will disclose that we will receive compensation for your health information if you authorize us to sell it, and we will stop any future sales of your information to the extent that you revoke that authorization.

15. Change of Ownership

In the event that this medical practice is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.

USES AND DISCLOSURES WITH YOUR OPPORTUNITY TO AGREE OR OBJECT

Unless you object, we may disclose your health information to:

Family and Friends

We may disclose health information about you to a family member, friend, or other person you indicate is involved in your healthcare or payment for your care. We will only disclose information directly relevant to that person's involvement in your care.

We may also use or disclose your health information to notify or assist in notifying a family member, your personal representative, or another person responsible for your care about your location, your general condition, or, unless you had instructed us otherwise, in the event of your death.

If you are unable to agree or object (e.g., in an emergency), we may disclose such information if we determine it is in your best interest based on our professional judgment. In the event of a disaster, we may disclose information to a relief organization so that they may coordinate notification efforts. We may also disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances.

If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures.

Disaster Relief

We may disclose your health information to disaster relief organizations so your family can be notified about your condition, status, and location.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

1. RIGHT TO INSPECT AND COPY

You have the right to inspect and receive a copy of your health information that may be used to make decisions about your care, including medical and billing records.

How to Exercise This Right:

Submit your request in writing to our Compliance Officer detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format

We have 30 days to respond to your request (with possible 30-day extension if needed)

We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can't agree and we maintain the record in an electronic format, your choice of a readable electronic or hard copy format

We will also send a copy to any other person you designate in writing

We may charge a reasonable, cost-based fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary

We may deny your request in limited circumstances:

If we deny your request to access your child's records or the records of an incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial harm to the patient, you will have a right to appeal our decision

If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional

If we deny your request, you have the right to request a review of that denial

2. RIGHT TO AMEND

If you believe information in your record is incorrect or incomplete, you may request that we amend it.

How to Exercise This Right:

Submit your request in writing and include a reason for the amendment

We are not required to change your health information, and will provide you with information about this medical practice's denial and how you can disagree with the denial

We may deny your request if:

The information was not created by us (unless the person or entity that created the information is no longer available to make the amendment)

The information is not part of the records we maintain

The information is not information you would be permitted to inspect and copy

The information is accurate and complete as is

If we deny your request:

You have the right to submit a written statement of disagreement

We may, in turn, prepare a written rebuttal

All information related to any request to amend will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information

3. RIGHT TO AN ACCOUNTING OF DISCLOSURES

You have the right to request an "accounting of disclosures" - a list of certain disclosures we have made of your health information.

What is NOT included in an accounting:

Disclosures for treatment, payment, or healthcare operations

Disclosures made to you

Disclosures made pursuant to your written authorization

Disclosures for notification and communication with family members or others involved in your care

Disclosures for national security or intelligence purposes

Disclosures to correctional institutions or law enforcement officials (when you are in lawful custody)

Disclosures for purposes of research or public health which exclude direct patient identifiers

Disclosures that are incident to a use or disclosure otherwise permitted or authorized by law

Disclosures to a health oversight agency or law enforcement official to the extent we have received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities

How to Exercise This Right:

Submit your request in writing stating the time period desired (not more than 6 years prior to the date of your request)

The first accounting in a 12-month period is free; subsequent requests may incur a reasonable fee

4. RIGHT TO REQUEST RESTRICTIONS

You have the right to request restrictions on how we use or disclose your health information for treatment, payment, or healthcare operations. You may also request restrictions on disclosures to family members or others involved in your care.

We are NOT required to agree to your request, except in one specific situation:

If you pay for a service or healthcare item out-of-pocket in full, you can request that we not share information about that service with your health insurer, and we must honor that request.

How to Exercise This Right:

Submit your request in writing to our Compliance Officer

State what information you want to limit

State whether you want to limit our use, disclosure, or both

State to whom you want the limits to apply

5. RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS

You have the right to request that we communicate with you about health matters in a certain way or at a certain location.

Example: You may request that we contact you only at work or only by mail.

How to Exercise This Right:

Submit your request in writing to our Compliance Officer

Specify how or where you wish to be contacted

We will accommodate all reasonable requests

6. RIGHT TO A PAPER COPY OF THIS NOTICE

You have the right to a paper copy of this Notice at any time, even if you have previously agreed to receive this Notice electronically.

How to Exercise This Right:

Contact our Compliance Officer at the number listed at the beginning of this Notice

You may also obtain a copy of this Notice at our website: [insert website if applicable]

7. RIGHT TO BE NOTIFIED OF A BREACH

You have the right to be notified in the event that we (or a Business Associate) discover a breach of your unsecured protected health information.

We will notify you:

Within 15 days of discovery of the breach (updated 2024 requirement)

By first-class mail to your last known address

If you have provided us with a current email address, we may use email to communicate information related to the breach

By telephone or other means if there is imminent threat to health or safety

In some circumstances our business associate may provide the notification on our behalf

We may also provide notification by other methods as appropriate

CHANGES TO THIS NOTICE

We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future.

Until such amendment is made, we are required by law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received.

If we make material changes to this Notice:

We will post the new Notice in our office reception area

We will post the new Notice on our website (if applicable)

We will provide you with a copy of the new Notice at your next visit or upon request

We will keep a copy of the current notice available at each appointment

The effective date will be listed at the top of the Notice

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with:

Our Practice:
Dr. Athena Payne, D.C., Compliance Officer
Rejuvenate Health and Wellness Centers
4255 Bryant Irvin Road, Suite 108
Fort Worth, TX 76109
Phone: 817-731-4848
Email: [email protected]

U.S. Department of Health and Human Services:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 1-877-696-6775
Email: [email protected]
Website: www.hhs.gov/ocr/privacy/hipaa/complaints/

The complaint form may be found at:
www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf

You will NOT be retaliated against or penalized in any way for filing a complaint.

QUESTIONS

If you have questions about this Notice, please contact:

Dr. Athena Payne, D.C., Compliance Officer
Phone: 817-731-4848
Email: [email protected]

EFFECTIVE DATE: February 16, 2026
VERSION: 2.0 - Updated per June 2024 HIPAA Law Changes
NEXT REVIEW DATE: February 2027

DOCUMENT VERSION INFORMATION

Created By: Dr. Athena Payne, D.C., HIPAA Compliance Officer
Version: 2.0
Supersedes: Version 1.0
Compliance Standards: 45 CFR Parts 160 and 164 (HIPAA Privacy Rule); June 2024 HIPAA Updates (42 CFR Part 2 - Substance Abuse Information)
Authorization: Dr. Athena Payne, D.C., Practice Owner & Compliance Officer
Retention: 6 years from date last in effect
File Location: HIPAA Compliance Manual - Section 2: Notice of Privacy Practices