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.


Rejuvenate is dedicated to maintaining the privacy of your protected health information (PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law (the Health Insurance Portability and Accountability Act of 1996 or HIPAA) to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our health center concerning your PHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

  • Your privacy rights concerning your PHI
  • How we may use and disclose your PHI
  • Our obligation concerning the use and disclosure of your PHI


The terms of this notice apply to all records containing your PHI that are created or retained by Rejuvenate. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our health center has created or maintained in the past, and for any of your records that we may create or maintain in the future. Rejuvenate will post a copy of our current notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.


Dr. Scott Symes, Privacy Officer 400 SW Longview Blvd Suite 160 Lees Summit, MO  64081 Phone: (816) 761-3944


For Treatment: We may use your PHI to provide you with treatment or services. We may disclose your PHI to doctors, nurses, technicians, other counselors in Rejuvenate, practicum students, or other personnel who are involved in taking care of you now or in the future. We also may disclose your PHI to people outside of the health center who may be involved in your medical care.

We may also use your PHI to call you, or send you a letter to remind you about an appointment, to follow up with diagnostic test results, or to provide you with information about other treatment and care that could benefit your health

For payment: We may use and disclose your PHI so that the treatment and services you receive at the health center may be billed and payment may be collected from you, an insurance company, or a third party.

For healthcare operations: Our health centers may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your PHI for our operations, our health center may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our health centers.


Business Associates: We will share your PHI with our business associates that perform functions on our behalf or provide us with services if the PHI is necessary for such functions or services. Whenever any arrangement between our health center and a business associate involves the use of disclosure of your PHI, we will have a written contract with the business associate that contains terms that will protect the privacy of your PHI.

Communication with others involved with your care: Our health professionals may, in the event you are incapacitated or in an emergency circumstance, using their judgment, disclose to a family member, or other relative, close personal friend, or any other person you identify, your PHI directly relevant to that person’s involvement in your care or payment related to your care.

Research: Under certain circumstances, we may use and disclose your PHI for research purposes. All research projects, however, are subject to a special approval process designed to protect the privacy of your PHI.

Required by law: We may use or disclose your PHI to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.  You will be notified, if required by law, of any such disclosures.

Public Health Risks: Our health center may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:

  • Maintaining vital records, such as births and deaths
  • Reporting child abuse or neglect
  • Preventing or controlling disease, injury, or disability
  • Notifying a person regarding potential exposure to a communicable disease
  • Notifying a person regarding a potential risk for spreading or contracting a disease or condition
  • Reporting reactions to drugs or problems with products or devices
  • Notifying individuals if a product or device they may be using has been recalled or withdrawn, needs repairs or replacement
  • Notifying appropriate government agency (ies) and authority (ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are require or authorized by law to disclose this information
  • Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance


Health Oversight Activities: Our health center may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

Legal Proceedings: We may disclose your PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal, in certain conditions in response to a subpoena, discovery request or other lawful purpose.

Law Enforcement: We may release PHI if asked to do so by a law enforcement official:

  • Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
  • Concerning a death we believe may have resulted from criminal conduct
  • Regarding criminal conduct at on our premises
  • In response to a warrant, summons, court order, subpoena or similar legal process
  • To identify/locate a suspect, material witness, fugitive or missing
  • In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)


Deceased Patients: Our health center may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for coroners, medical examiners or funeral directors to perform their jobs.

Organ and Tissue Donation: If you are an organ or tissue donor, our health center may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation.

Serious Threats to Health or Safety: Our health center may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public.  Under these circumstances, we will only make disclosures to a person or organization who may be able to help prevent or lessen the threat.

Military: Our health center may disclose your PHI if you are a member of the U.S. Armed Forces, a veteran, or a member of foreign military forces for activities deemed necessary by appropriate military command authorities, including the Department of Veteran’s Affairs for the purpose of your eligibility for or entitlement to certain benefits provided by law.

National Security: Our health center may disclose your PHI to authorized federal officials for intelligence, counter-intelligence and national security activities authorized by law. We also may disclose your PHI to authorized federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

Inmates: Our health center may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you; (b) for the health, safety and security of the institution, and its officers and employees and/or (c) to protect your health and safety or the health and safety of other individuals.

Workers Compensation: Our health center may release your PHI for workers compensation and similar programs.

Required Uses and Disclosures: Under the law, we must make disclosures to you and, when required by the Secretary of the Department of Health and Human Services, to investigate or determine our compliance with the requirement of Section 164.500 et. seq.

We will not use your PHI for marketing purposes.Other uses and disclosures from your medical record will be made only with your written authorization or approval. This includes most uses and disclosures of psychotherapy notes, unless the disclosure is required by law and for other limited purposes. It also includes disclosure of your PHI that would constitute a “sale” of the PHI.


You have the following rights regarding the PHI that we maintain about you:

  1. Confidential Communications. You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, please contact the Privacy Officer at the address or phone number listed in paragraph B, above, to make an appointment to complete the form.You do not need to give a reason for your request.
  2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request, except for certain disclosures to health plans as noted below. However, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to the Privacy Officer at the address or phone number listed in paragraph B, above. Your request must describe in a clear and concise fashion:

(a)    the information you wish restricted;

(b)    whether you are requesting to limit our health center’s use, disclosure or both; 

(c)       to whom you want the limits to apply.

  1. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records. However, you may not obtain psychotherapy notes or information compiled in reasonable anticipation of a civil, criminal or administrative action or proceeding. You must submit your request in writing using the contact information below in order to inspect and/or obtain a copy of your PHI. Our health center may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Upon request, we will provide you with an electronic copy of the PHI that we maintain electronically.
  1. Amendment. You may ask us to amend your PHI if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by our health center. To request an amendment, your request and reason for the request must be made in writing. You must provide us with a reason that supports your request for amendment. Our health center will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the health center; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) was not created by our health center, unless the individual or entity that created the information is not available to amend the information.


  1. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures”. An “accounting of disclosures” is a list of certain non-routine disclosures our health center has made of your PHI for non-treatment or operations purposes. Use of your PHI as part of the routine patient care in our health center is not required to be documented. For example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to the Privacy Officer at the address or phone number listed in paragraph B, above. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date the “accounting of disclosures” is The first list you request within a 12-month period is free of charge, but our health center may charge you for additional lists within the same 12-month period. Our health center will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
  2. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time by contacting the Privacy Officer at the address or phone number listed in paragraph B, above.
  3. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with Rejuvenate or with the Secretary of the Department of Health and Human Services. You will not be retaliated against for filing a complaint. To file a complaint with our health center, use the contact information below.
  4. Right to Provide an Authorization for Other Uses and Disclosures. Our health center will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the Please note: We are required to retain records of your care.
  5. Right to Restrict Disclosures to Your Health Plan. If you have paid out-of-pocket in full for any services provided at our health center, and you ask us not to disclose that PHI to your health plan, we will honor the request, except where we are required by law to make a
  6. Right to Notification of a Breach of Your PHI. If there is improper access, use or disclosure of your PHI that meets the legal definition of a “Breach” of your PHI, we will notify you in