YOUR PRIVACY, MADE CLEAR
WHAT IS THE NOTICE OF
PRIVACY PRACTICES?
1
As a new patient, your first step is simply sharing a bit about yourself. The form below helps us understand your health history, current concerns, and goals so your visit can be focused, comfortable, and personalized from the start.
WHY DO I NEED TO REVIEW AND ACKNOWLEDGE IT?
2
This notice ensures you’re informed about how your information is handled and confirms that you understand your rights as a patient. Acknowledging it is a standard part of care and helps us remain transparent and compliant with privacy regulations.
HOW LONG DOES IT TAKE
TO COMPLETE?
3
Most patients complete the form in about 10–15 minutes. It’s straightforward, can be completed at your convenience, and is securely submitted online.
WHAT HAPPENS AFTER I
SUBMIT IT?
4
Once submitted, your acknowledgment is securely stored in your patient record. No further action is needed, you’ll be all set, and your care can move forward without any delays at your visit.
Step 1 of 5
Notice of Patient
Privacy Practices
Please read the following notice carefully before proceeding with your intake.
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.
This Notice of Privacy Practices describes how Brighton Campus Chiropractors, LLC may use and disclose your health information and how you can access this information. This Notice explains how we use and share your health information and describes your rights and our legal duties under federal and state privacy laws.Who This Notice Applies To
This Notice of Privacy Practices applies to our chiropractic practice and all related services we provide, including those performed by our support staff and business associates who help deliver or manage your care. We follow the requirements of the Health Insurance Portability and Accountability Act (HIPAA). This Notice applies to you as a patient of our practice and to any services we provide in connection with your care.If you have any questions about this Notice, please contact our Privacy Officer or any staff member in our office.
Privacy Officer: Louis S Catapano | Practice: Brighton Campus Chiropractors, LLC | Address: 2024 W Henrietta Rd, Rochester, NY 14623 | Phone: (585) 272-7340
Our Obligations
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; and follow the terms of the Notice currently in effect.We may change the terms of this Notice from time to time. When we make a significant change, we will post the revised version in our office and, if applicable, on our website. You may obtain the current version at any time by contacting our Privacy Officer or asking at the front desk.
What Is Protected Health Information (PHI)?
Protected Health Information (PHI) is information about you that may identify you and relates to your past, present, or future physical or mental health condition, the provision of health care to you, or payment for that care.Uses and Disclosures Permitted Without Authorization
Federal law (HIPAA) permits us to use and disclose your protected health information for treatment, payment, and health care operations without a separate written authorization, as described in this Notice.Treatment — We may use or disclose your PHI to provide, coordinate, or manage your health care and related services.
Payment — We may use or disclose your PHI to obtain payment for services provided to you.
Health Care Operations — We may use or disclose your PHI to support the business operations of this practice.
Business Associates
We may share your PHI with third-party "business associates" who perform services for us (such as billing, IT support, or transcription). These entities are required by contract to protect the privacy and security of your PHI.Uses and Disclosures Requiring Your Written Authorization
Other uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law. These include:• Disclosures of psychotherapy notes
• Uses and disclosures for marketing purposes
• Disclosures that constitute a sale of PHI
• Other uses and disclosures not described in this Notice
Substance Use Disorder (SUD) Records — 42 C.F.R. Part 2
Certain records related to Substance Use Disorder (SUD), if present in your record, receive additional confidentiality protections under federal law (42 C.F.R. Part 2). Our primary services are chiropractic care. If our office maintains such information, those records generally will not be used or disclosed without your specific written authorization, except as otherwise permitted or required by federal law.Other Permitted and Required Uses and Disclosures
We may use or disclose your PHI without your authorization for: Public Health & Safety, Health Oversight, Abuse/Neglect/Domestic Violence reporting, Workers' Compensation, and as Required by Law.Legal Proceedings & Law Enforcement
We may disclose PHI in response to a valid court order, subpoena, discovery request, or other lawful process as permitted by law.Your Rights
You have the right to: Inspect and Copy your PHI; Request Restrictions on certain uses; Request Confidential Communications; Amend your PHI; receive an Accounting of Disclosures; receive Breach Notification; and request a Paper Copy of this Notice. To exercise any of these rights, please submit a written request to our Privacy Officer.Complaints
If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the U.S. Department of Health and Human Services at www.hhs.gov/hipaa or 1-800-368-1019. You will not be penalized for filing a complaint.Effective Date
This Notice of Privacy Practices is effective as of February 1, 2026.Step 2 of 5
Patient
Information
Please fill out all fields accurately. This information is confidential.
Step 3 of 5
Symptoms &
Health Check
Check any symptoms you currently have or have had previously. Use the arrows to move through each category.
Step 4 of 5
Medical
History
Please provide the approximate dates of your most recent examinations and answer the questions below.
Step 5 of 5
Consent &
Signature
Please review, acknowledge, and sign below to complete your intake.
Sign in the box below using your mouse or finger.
Form Submitted
Thank you for completing your patient intake. Our team at Brighton Campus Chiropractors, LLC will review your information before your appointment. If you have any questions, please call (585) 272-7340.