279 Main Street.

(308) 432-3518

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Effective Date 11/21/2023

New Patient Forms- Required

Please fill out and submit the appropriate Adult or Child (Age 18 years and younger) Intake Form below, prior to your appointment.   You may call us at (308) 432-3518 to schedule an appointment.

Patient Intake Form - Adult                      Patient Intake Form - Child                    

Annual Consent Forms (current patients only)

Please fill out and submit the appropriate form below.  

Annual Consent Forms - Adult                        Annual Consent Forms - Child Under the age of 19

Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!

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Notice of Privacy Practices                                                                                           September 19, 2014

As required by the Health Insurance Portability and Accountability Act (HIPPA) Omnibus Rule March 26, 2013 Chadron Chiropractic, PC through it Officers of the Board of Directors, physicians and staff employees, endeavor to protect the privacy and confidentiality of all patient’s and employee’s protected health information(PHI).


  1.  Definition of protected health information.  PHI means any information whether oral or recorded in any form or medium that is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearing house; and relates to the past, present or future physical or mental health or condition of an individual; the provision of health care to an individual’ or the past, present, future payment for the provision of health care to an individual.
  2. As a health care provider, as defined by HIPPA, the physician and staff of Chadron Chiropractic, PC are required to maintain the confidentiality, or privacy, of protected health information and to notify patients of our intent to do so.
  3. As a health care provider, we are committed to use and disclose PHI, with or without authorization with judicial caution whereby only the required, or minimum necessary PHI is disclosed, at any given time, and then only to known and trusted entities or business associates who will also safeguard this PHI with their best efforts.
  4. Patients have the right to access and control the use and disclosure of their PHI designated records.  Notice of Privacy Practices which is attached hereto and made a part hereof.  Patients also have the right to copies of PHI produced by Chadron Chiropractic, PC about their past, present, and future condition.  Patients also have the right to request amendments or corrections to their PHI.  Amendment or correction requests must be made in writing.  The decision whether or not the request or amendment or correction will be granted lies with the provider who produced or ordered the PHI and whether or not action has already been taken based on the PHI as written however, the written request of the change will be maintained with health records.
  5. The procedures to implement of the Notice of Privacy Practices Policy and Procedures is as follows:
  1.  A notice of Privacy Practices will be prepared, updated as required and maintained as a part of this procedure.
  2. A Notice of Privacy Practices will be delivered to patients by any of the means:
  1.  In person, such as patient’s first encounter in the office will be offered a Privacy Notice to keep.
  2. By mail, such as in statement, appointment or informational mailings.
  3. A Notice of privacy practices will be available for viewing in the treatment rooms.
  4. Notice of Privacy Practices will be given or mailed to the parent or guardian in the case of a minor child, or to the Personal Representatives in the case of an incompetent or a person who is blind or one who is not capable of acknowledging receipt of the Notice of Privacy Practices.


Uses and disclosures for marketing purposes; and uses and disclosures that constitute the sale of PHI will require a written authorization from the individual.

 Marketing                                                                                                                                                                              Chadron Chiropractic, PC must obtain written authorization to use and disclose PHI for marketing purposes, including most non-face-to-face communications when the provider receives payment to make the communication.  If payment is involved, the marketing authorization must disclose the fact.  However, Chadron Chiropractic, PC may inform a patient about a third party’s product or service without the patient’s written authorization when Chadron Chiropractic, PC does not receive any compensation for the communication.  The communication is face-to-face; the communication involves a product the patient is being instructed to use the payment is limited to reasonable reimbursement of the costs of communication; and the communication involves general health promotion.  Chadron Chiropractic, PC is still permitted to give patients promotional gifts of nominal value.

Fundraising                                                                                                                                                          Chadron Chiropractic, PC now may disclose more information to institutionally-related foundations for fundraising, but they must explain how the recipient may opt-out of receiving future fundraising communications.  If an individual opts-out, Chadron Chiropractic, PC must not make any further communications to the individual.

Restrict disclosure to health plans

You have the right to request restrictions on certain uses and disclosures of your PHI. Requests must be made in writing with information you want to limit and to whom you wants the limits to apply.  Chadron Chiropractic, PC will comply with a request for restrictions on disclosures made to health plans for payment or health care operations purposes if the PHI to an item or service for which the individual paid completely out-of-pocket.

Breach of notification statement

Chadron Chiropractic, PC has the highest ethical obligation in       protecting our patient’s health information, has taken safeguards that are effective and perform a periodic in-house policy conduct review of identifying safeguards.   However, in compliance with HIPPA Omnibus Rule 3-26-2013, Breach of Notification Rule, if a breach demonstrates that a person’s PHI has been compromised said person will be notified within 60 calendars days from when the breach was discovered, unless law enforcement requests a delay.

  Chadron Chiropractic, PC Forms of acknowledgement may be by:

a.  A copy of A Privacy Notice Written Acknowledgement will be filed with the patient’s PHI, and will be renewed each year.

b. Initialing and retaining a copy of the initialed Notice of Privacy Practices with the patient’s PHI.

Office Hours

Tuesday Business Office Only


8:00 am-5:00 pm


8:00 am-5:00 pm


8:00 am-5:00 pm


8:00 am-5:00 pm


8:00 am-12:00 pm






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