Please be advised that we reserve and exercise the right to update this page and its contents. We recommend you print this page and retain it for your records, as it will apply as of the date of your deposit or receipt of services, whichever is sooner.

This page was last updated on October 27, 2023.

Who We Are.

NeuroSynergy® Associates, PA (“NSA”) is a registered Florida Professional Association incorporated on October 28, 2015, with the registered number P15000088960. The company employs and contracts with multiple health professionals, including chiropractors, medical doctors, and other health professionals, to provide healthcare services and staffing. The company has one managing member, Matthew M. Antonucci, DC, DACNB, FACFN, FABCDD, FABVR, FABNN, FABBIR, FICC. Tricia Carrick serves as a principal of the company in the position of secretary. EIN: 47-5461747. Its legal location is 8910 Astronaut Blvd, Suite 102, Cape Canaveral, FL, 32920. The email address for communication is


PAYMENT IS REQUIRED BEFORE SERVICES ARE PROVIDED. Unless otherwise agreed upon in writing, NSA requires patients to pay before receiving services. All prepaid funds over USD 1,000.00 are held in a separate escrow account at an FDIC-insured bank. Your funds are not accessible to the practice or the doctor(s) until they are disbursed after services or goods have been provided or under practice policies (including fees).

We accept cash, Electronic Funds Transfer (ETF/ACH Payments), bank checks (no personal checks), and credit cards, including Apple Pay, VISA, MasterCard, Discover, and American Express. We offer a 3% discount on cash and ACH transactions when requested. Before your appointment, any other payment arrangements should be cleared with NeuroSynergy® Associates’ staff. If you are experiencing financial hardship and require special arrangements, please notify us before receiving care. Financing options and/or payment plans may be available.

Dr. Antonucci is a highly-desired, low-volume practitioner. By scheduling an appointment, you are taking one of a limited number of appointments available. Therefore, to secure an intake date, a deposit is required. Per Minnesota law, you have 72 hours from the timestamp of your deposit payment to cancel your appointment without penalty and receive a full refund (unless laboratory testing was ordered). Your deposit is held in an escrow account and is not accessible to the practice until it is drawn upon for a service or a fee.

  1. If you authorize laboratory testing to be ordered, the amount of the laboratory testing costs plus an administration fee (including an interpretative report) of $275 will be deducted from your deposit. 
  2. If you cancel or reschedule 14 or more days from your appointment, a fee of 25% of the remaining deposit will be drawn.
  3. If you cancel or reschedule between days 13 and 7 before your scheduled appointment, a fee of 50% will be drawn.
  4. If you cancel or reschedule within the six days preceding your appointment, a fee of 100% will be drawn against your deposit, and you will have no eligible refund. 

---There will be NO exceptions to this policy.---

Service Charges

Patients are not permitted to carry an account balance.

 All payments must be made at the time of, or before services are provided. There is a $200 charge for each payment returned, reversed, or unpaid by your bank or credit card for any reason. Returned, unpaid checks will create an account balance. Therefore, a service charge will be added to accounts unpaid after 30 days. This charge is 2% per month, compounding. A positive account balance with NeuroSynergy® Associates will render a patient ineligible to schedule a future appointment, and NeuroSynergy® Associates, PA has the right to cancel future appointments, subject to the Terms and Conditions of Deposit policy until the balance is paid in full. NeuroSynergy® Associates will submit any outstanding balances over 90 days past due to a collection agency, which may impact your creditworthiness.

By submitting payment, you authorize NSA to collect and escrow your deposit and apply the policy above/formula.   

When making a prepayment on a care plan, NSA must provide you a plan in writing, which will need to be signed by both you and your doctor before commencing treatment. You can cancel your appointment with a complete deposit refund if you do not receive a signed copy of this care plan before beginning treatment. A copy will be provided to you, and a copy will be maintained in your record.

Late Arrival and Missed Appointment Policy

Our doctors and staff attempt to answer all questions and provide a comprehensive service to EACH patient. We will do our best to honor your time by staying on schedule. Please help us by arriving on time for your appointments with all paperwork completed before arrival.

  1. If you arrive late, the time missed may be deducted from your appointment. You may be asked to forfeit the remaining session if you are more than 30 minutes late for a treatment. If a patient misses an appointment or is more than 30 minutes late due to a non-extenuating circumstance or without notice, we will not refund or re-schedule the missed appointment.
  2. If an appointment is missed due to extenuating circumstances beyond your control (weather, acts of God, medically documented illness, etc.), we will try our best to deliver your entire treatment session as indicated by the clinician. Traffic, oversleeping, delayed flights, and other preventable circumstances are not considered extenuating.
  3. A refund or credit may apply if you have a valid and documented medical reason.

Recording of Image and Likeness

The doctors may record examinations, diagnostics, and/or treatments for your clinical benefit and professional education purposes. The staff of NeuroSynergy® Associates is actively involved in educating doctors to advance care for various neurological conditions. These videos afford an educational experience, allowing other doctors to help individuals like you. You also have a right to the recording, should you choose to review it. If you do not want to be recorded, please let us know. We will ask you and your doctor to sign an agreement stating so.

Policy on Health Insurance Billing and Documentation

NeuroSynergy® Associates is a “direct-pay” practice. This means we DO NOT accept assignments or bill any government or private insurance nor participate in any part of the insurance process. Upon request, we will provide an itemized invoice containing a non-coded description of the test/procedures performed and the quantity of tests/procedures performed, within five business days of the request. We do not provide insurance diagnosis codes (ICD), and procedure codes (CPT), complete/file insurance forms, or create insurance bills. There are no exceptions to this position.
If you require third-party coding, you can decline service with us, or we can provide you with a copy of your records and recommend you to a billing and coding specialist. Other than advising you to a specialist and providing your health records, we cannot provide additional support in the reimbursement process. A written report (case summary) may be requested and furnished at an additional cost of $1000. We do not make or imply any guarantees of reimbursement or “coverage” of our services by third parties.

There are no exceptions to this policy.


NSA and its affiliates participate in clinical research. By receiving services, you consent to your anonymized data for clinical research. All data collected during your care may be de-identified and used for analysis. The results of these analyses may be used as part of medical and non-medical publications. At no point will a person outside of our organization, or an individual not bound by a Business Associates Agreement (BAA), be able to identify you from your data.


The Company operates out of a facility with patients, staff, visitors, and other traffic in and out of the facility. Please maintain possession of your belongings at all times. If you see an unattended possession in the facility, please alert the front-office staff. Our staff is prohibited from supervising or holding your possessions. Under no circumstances will the Company be responsible for lost, stolen, or broken items, possessions, or property.

For your safety, the Company’s policy is to restrict patients from touching, unsupervised utilization of, and/or removing equipment from the facility. We require all patients to adhere to this policy or you may be subject to discharge from care without warning


You have a right, as a patient, to be informed about the condition of your health and the recommended care and treatment to be provided to you so that you can decide whether to undergo such care with full knowledge of the known risks. This disclosure is not intended to frighten or alarm you. It is intended to make you better informed so that you may knowledgeably give or withhold your consent.


NeuroSynergy® Associates is a treatment, teaching, and research entity staffed with licensed doctors of chiropractic, board-certified specialists, other medical professionals, licensed assistants, and student interns.

An assessment of every patient is performed, which may include a comprehensive and/or focal examination, which may include: a) the patient to remove some of their clothing, b) physical hands-on-body palpation/touching, c) the use of medical equipment, d) laboratory, orthopedic, neurological, and physiological testing (some of which may require piercing of the skin with prior additional consent). Therapies performed at the Company do not include the use of drugs or surgical procedures. Like physical therapy, rehabilitation therapies may be included in management protocols to support the chiropractic adjustment. These therapies may be done manually (by hand) or through digital and/or mechanical technologies. Such therapies may include but are not limited to: Low Low-Levelt Therapy, Transcutaneous Electric Nerve Stimulation, Orthoptic/Vision Therapies, Vestibular Rehabilitation Procedures, Neuromuscular Reeducation, Occupational Therapy, Speech Therapy, Therapeutic Strength Training, Myofascial Therapies, Neurocognitive Therapy, Biofeedback, Neurofeedback, Psychotherapy, and/or Chiropractic Manipulation.


Matthew M. Antonucci, DC, DACNB, FACFN, FABCDD, FABVR, FABNN, FABBIR, FICC (“Dr. Antonucci”) is a board-certified chiropractic neurologist. He is not a medical doctor (“an M.D”). He is actively practicing and board-certified in Chiropractic Neurology (DACNB) through the American Chiropractic Neurology Board. He is fellowship board certified in Functional Neurology (FACFN), Childhood Developmental Disorders (FABCDD), Vestibular Rehabilitation (FABVR), Nutrition and Neurochemistry (FABNN), and Brain Injury and Rehabilitation (FABBIR) through the American College of Functional Neurology. He also holds an honorary fellowship from the International College of Chiropractors (FICC). He has been certified by the National Board of Chiropractic Examiners to perform physiotherapy (“rehabilitative therapies”) modalities.

Dr. Antonucci maintains active chiropractic licenses in good standing, in the following states: Florida (CH 11693), Minnesota (7006), Colorado (CHR.0008179), and Utah (9410826-1202). He holds inactive chiropractic licenses in good standing, in Georgia (CHIR009016), and South Carolina (3613).

Chiropractic Care

The care being provided by Dr. Antonucci falls under the practice and scope of chiropractic and no other occupation. 

  • Chiropractic is defined as the health care discipline that recognizes the innate recuperative power of the body to heal itself without the use of drugs or surgery by identifying and caring for vertebral subluxations and other abnormal articulations by emphasizing the relationship between structure and function as coordinated by the nervous system and how that relationship affects the preservation and restoration of health.
  • Chiropractic services mean the evaluation and facilitation of structural, biomechanical, and neurological function and integrity through the use of adjustment, manipulation, mobilization, or other procedures accomplished by manual or mechanical forces applied to bones or joints and their related soft tissues for the correction of vertebral subluxation, other abnormal articulations, neurological disturbances, structural alterations, or biomechanical alterations, and includes, but is not limited to, manual therapy and mechanical therapy. 
  • Chiropractic Manipulation is the application of a high-velocity, low-amplitude (HVLA) movement of a joint to restore joint integrity, thus removing neurological interference. There are many different methods or techniques by which Doctors of Chiropractic perform manipulations. These manipulations may be delivered by hand or by an instrument.
  • “Rehabilitative therapy" means therapy that restores an ill or injured patient to the maximum functional improvement by employing within the practice of chiropractic those methods, procedures, modalities, devices, and measures which include mobilization, thermotherapy; cryotherapy; hydrotherapy; exercise therapies; nutritional therapy; meridian therapy; vibratory therapy; traction; stretching; bracing and supports; trigger point therapy; massage and the use of forces associated with low voltage muscle stimulation, high voltage muscle stimulation, ultraviolet light, red and infrared light, magnetic fields, supplemental oxygen (at varying pressures), diathermy, and ultrasound; and counseling on dietary regimen, sanitary measures, orthpotic training, functional cognitive therapies, occupational health, lifestyle factors, posture, rest, work, and recreational activities that may enhance or complement the chiropractic adjustment. 
  • Therapeutic services are performed within a practice where the primary focus is the provision of chiropractic services, to prepare the patient for chiropractic services or to complement the provision of chiropractic services.
  • Diagnostic services mean clinical, physical, laboratory, and other diagnostic measures, including diagnostic imaging that may be necessary to determine the presence or absence of a condition, deficiency, deformity, abnormality, or disease as a basis for evaluation of a health concern, diagnosis, differential diagnosis, treatment, further examination, or referral. 
  • An individual licensed to practice chiropractic under section 148.06 is authorized to perform chiropractic services, acupuncture, and therapeutic services, and to provide diagnoses and to render opinions about those services to determine a course of action in the best interests of the patient, such as a treatment plan, appropriate referral, or both.

Risks Associated with Treatment/Care

In addition to the benefits of such applications, one should be aware of some risks and limitations of such treatments. The risks are seldom high enough to contraindicate their use but should be considered when receiving such treatments. All health procedures have some inherent risk associated with them. The risks associated with chiropractic treatments may include but are not limited to, musculoskeletal sprain/strain, scratches, bruising, neurological injury, fracture, vertebral artery syndrome (VAS), stroke, dismemberment, and in extremely rare circumstances death through complicating factors (1 occurrence in 8,060,000 office visits, or 1 in 5,850,000 cervical manipulations [Sudden Neck Movement and Cervical Artery Dissection: The Chiropractic Experience, CMAJ 2001; 165(7):905–906]). Risks associated with rehabilitative procedures may include all of the preceding and allergic reactions, choking, burns, vertigo, syncope, myocardial infarction, broken bones, nausea, vomiting, headache, seizures, falls, retinal damage, cuts, infections, ear damage, and more.

As of September 2023, the Company has treated thousands of patients with 0 reports or incidences of anything more than mild complications. No patient has ever reported being harmed. Dr. Antonucci and NSA purposefully do not utilize the term “cure.” The terms "cure" or "guarantee to cure" or similar terms in advertisements are fraudulent and misleading to the general public. The advertising, by any means, of chiropractic practice, treatment, or advice in which untruthful, improbable, misleading, or impossible statements are made is prohibited by the state of Minnesota and the Minnesota Board of Chiropractic.

Outcomes and Expectations

Outcomes from a random sample of 63 patients with concussion symptoms who completed a 5-day program under the direction of Dr. Antonucci were analyzed by the biostatistics department at the University of Central Florida’s College of Medicine and published in a peer-reviewed journal. They found that the population's average duration of persisting concussion symptoms was 2.3 years. 96.8% of the sample experienced a decrease in symptom severity, an average of 60.1%. 3.2% experienced an increase in symptom severity and an average of 16.5%. The average count of symptoms (e.g.: headache, neck pain, dizziness = count of 3) decreased by 33.7%, indicating that ⅓ of the patients’ symptoms were eliminated entirely. The average symptom severity of the remaining symptoms decreased by 30%. This is offered as an example of actual patient results. Although there is a high probability of improvement, no outcome can be guaranteed.

If patients provide a testimonial, they can review advertisements that use their statements, likenesses, or case summaries before they are released for production, distribution, or display. Statements made by patients that are untruthful, improbable, misleading, or impossible will not be made publicly available, even if the patient made the statements.

Consent For Care

By partaking in services offered by the Company, you acknowledge you have been informed of the nature and purpose of chiropractic and ancillary treatments, the benefits, the risks, and the possible consequences of receiving treatment, including the risk that the care provided might not accomplish the desired objective(s). You also acknowledge that you had the opportunity to ask for clarification on any or all risks and alternatives, and had all of your questions answered to your complete understanding.

You understand that the clinical staff takes every precaution possible to reduce or mitigate the risk of each procedure and weighs the benefits and the risks before prescribing or implementing each therapy. Should you wish not to receive therapy, you can ask to be informed of reasonable alternative treatments at any time.

You understand that you have been informed of the risks, consequences, and probable effectiveness of each (above). I have been advised of the possible repercussions and potential efficacy of each. You acknowledge that no guarantees have been made concerning the risks of treatment, outcomes, or a cure.


If a dispute arises regarding the Company’s therapy, this agreement, or any aspect of patient care, the parties agree to resolve the matter between the parties. If the parties cannot come to an amicable agreement, the parties hereby agree to mediation or arbitration. The parties agree to submit the dispute to non-binding mediation with a mutually selected mediator. If mediation fails, the parties agree to resolve the matter through binding arbitration. The parties agree to use the American Arbitration Association or a mutually selected arbitrator service and/or arbitrator. The arbitration shall take place in the Orlando, Florida, area. The arbitrator shall have full power to rule on all dispute matters. The parties mutually agree to waive their right to a trial by jury. The prevailing party (who obtains most of the relief it seeks) is entitled to recover its reasonable and necessary attorney’s fees.

Waiver of Consequential Damages

By receiving care, you waive any indirect damages, including all claims of lost profits. 

Limitation of Liability- In no event shall the Company be liable for an amount more than the total clinic fee with the Patient. Additionally, under no circumstances shall the Company or any of the Company’s employees, owners, or officers be liable to the Patient for any claims and/or damages personally.


Permission to Share Personal Health Information

IMPORTANT: We cannot share your health information with any individual other than you, and the names that you provide us in writing, in the form of a Health Information Disclosure, unless mandated by law or to ensure proper medical care.

Unless an individual is under 18, incapacitated, or has a medical power of attorney (POA), we cannot share information with their spouse, parents, attorneys, or any individual unless permission is granted.

For clarification and example: A parent paying for (and even accompanying) their adult offspring is not privy to discussions, observing treatment, receiving records, billing information, or any part of the patient's care or health record, unless that adult offspring grants written permission.

If you wish to authorize disclosing my personal health information to the following healthcare providers, family members, caretakers, or individuals, please let our staff know.

You acknowledge and understand that as part of your healthcare, NSA originates and maintains health records describing your personal/confidential identification information, history, symptoms, examination and test results, diagnoses, treatment, and any plans for the future care of treatment.

You understand that this information serves as:

  • A basis for your identification
  • A means of communication among the health professionals who contribute to your care
  • A source of information for billing
  • A means to resolve any outstanding debts (including but not limited to collection agencies)
  • A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals. 

YOU GIVE PERMISSION TO NeuroSynergy® Associates, PA, THEIR STAFF, AND AFFILIATES to share your information with the staff, in-office associates, and providers that they feel it is necessary and appropriate to support your care, to increase your quality of care, to protect their interests, for office purposes, or when required to do so by law. 

You may request restrictions on disclosures. You may request changes to your records. The practice has the right to accept or deny your request. To protect your privacy, we will only disclose information to the individuals listed explicitly, unless law obligates us to, or to provide continuity of care.



Updated October 26, 2023

This Notice of Privacy Practices identifies the general ways your protected health information can be used or disclosed. Protected health information is the individually identifiable personal health information found in your medical and billing records. This information is created or received by a health care provider, insurance company, or employer, and relates to your past, present, or future physical or mental health conditions or the payment for health care services. This information can be transmitted or maintained in any form by NeuroSynergy Associates, PA.

This Notice describes your legal rights regarding your protected health information. It also informs you of the legal duties and privacy practices of NeuroSynergy Associates, PA.

For the purpose of this Notice, the terms “you” or “your” refers to the patient who is the subject of the protected health information. The terms “we”, “our” or “us” refers to NeuroSynergy Associates, PA.


We are required, by law, to keep your identifiable protected health information private; provide you with this Notice of our legal duties and privacy practices with respect to your protected health information, and follow the terms of the Notice as long as it is in effect. If we revise this Notice, we will follow the terms of the revised Notice, as long as it is in effect.


The following information describes how we are permitted, or required by law, to use and disclose your protected health information. Not every use or disclosure in a category will be listed.

Treatment: We may use or disclose your protected health information to a physician or other health care provider in order to provide care and treatment to you. For example, a physician treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. We also may disclose protected health information about you to those who may be involved in your health care outside of our facilities, such as hospitals, physicians, and others who provide you with follow-up care and medical equipment or product suppliers. We may contact you to provide appointment reminders and to provide you with information about health-related benefits and services provided by us, or treatment alternatives that may be of interest to you.

Payment: We may use or disclose your protected health information to obtain payment for services we provide to you. We may disclose your protected health information to another health care provider or entity. We may use or disclose your protected health information to a debt collector in order to settle an outstanding debt. For example, we may need to provide a third party with information about the medical care you received, the dates you received care, the amount you paid for care, your response to care, and more. We may tell a third party about a treatment you are going to receive to obtain the third party’s prior approval for this treatment or to determine whether the party will cover the treatment.

Health Care Operations: We may use or disclose protected health information about you to support our programs and activities such as quality and service improvement; health care delivery review; regulatory compliance, staff performance evaluation; competence or qualification review of health care professionals; education and training of physicians and other health care providers; and business planning and development, business management and general administrative activities. We use this information to continuously improve the quality of care for all patients we serve. For example, we may combine protected health information about many patients to evaluate the need for new services or treatments. We may disclose information to doctors, nurses, and other students for educational purposes. We may also combine protected health information we have with that of other facilities to see where we can make improvements.

Additionally, we may share your protected health information with other health care providers and payors for certain of their business operations if the information is related to a relationship the provider or payor currently has or previously had with you, and if the provider or payor is required by federal law to protect the privacy of your protected health information.

Health Information Exchange (HIE): We may make your protected health information available electronically through an information exchange network to other providers involved in your care who request your electronic protected health information. The purpose of this information exchange is to support the delivery of safer, better-coordinated patient care. Participation in the information exchange is voluntary. If you do not want your protected health information to be accessible to authorized health care providers through the HIE, you may submit a signed non-participation (opt-out) form, available at the time of registration. If you decide not to participate, health care providers will not be able to access your protected health information through the HIE.

Authorization for Other Disclosures: We will not use or disclose your protected health information, except as described throughout this document, unless you authorize us, in writing, to do so. You can revoke an authorization at any time, in writing. If you revoke an authorization, we will no longer use or disclose your protected health information for the purpose covered by the authorization. However, we are unable to take back any uses or disclosures already made with your authorization. Specific examples of uses or disclosures requiring authorization include the use of therapy notes, marketing activities, the sale of your protected health information, and most non-treatment uses and disclosures for which we are compensated.

Family and Friends: We may use or disclose your protected health information to notify or assist in notifying a family member, personal representative, or other persons responsible for your care, of your location and general condition. We will also disclose protected health information to a family member, other relatives, close personal friend, or any other person you identify if the information is relevant to that person’s involvement with your care or payment for your care. You can prohibit disclosure of this information.

Fundraising: We may use or disclose certain protected health information about you to an institutionally related foundation to contact you in an effort to raise money for our organization and its operations. Only contact information such as your name, address, and telephone number, and information related to the department of your service, your treating physician, outcome information, health insurance status, and the dates you received treatment or services with NeuroSynergy Associates would be released. You have the right to opt-out of fundraising communications at any time and your request must be honored. Any such communication will have clear and conspicuous instructions on how to opt-out of future fundraising communications.

Future Communications: We may use or disclose your information to communicate with you via newsletters, mailings, or other means regarding treatment options, health-related information, disease-management programs, wellness programs, or other community-based initiatives or activities in which we participate. If we receive any financial compensation for such communications (with limited exceptions), we will obtain your authorization prior to sending the communication and your authorization can be revoked at any time.

Public Health and Safety: We may use or disclose your protected health information, as authorized or required by local, state, or federal law, for the following purposes deemed to be in the public interest or benefit:

To report certain diseases and wounds, births and deaths, and suspected cases of abuse, neglect, or domestic violence;
To help identify, locate, or report criminal suspects, crime victims, suspicious deaths, or criminal conduct on the premises of NeuroSynergy Associates or their affiliates;
To respond to a court order, subpoena, or other judicial processes;
To assist federal disaster relief efforts;
To enable product recalls, repairs, or replacements;
To respond to an audit, inspection, or investigation by a health-related government agency;
To assist in federal intelligence, counterintelligence, and national security issues;
To facilitate organ and tissue donations;
To assist coroners, medical examiners, and funeral directors;
To respond to a request from a jail or prison regarding an inmate’s health or medical treatment;
To respond to a request from your military command authority (if you are a member or veteran of the armed forces);
To provide information to a workers’ compensation program.

Business Associates: There are some services that we provide through contracts with business associates. When these services are contracted, we may disclose your protected health information to the business associate so they can perform the job we have asked them to do. However, business associates are required by federal law to appropriately safeguard your information.

Research: We will disclose information to researchers after approval by an Institutional Review Board (IRB) in preparation for a research study, to recruit research subjects, or for a research study. The IRB reviews research proposals and establishes protocols to protect your safety and the privacy of your protected health information.

Confidential Communications: You have the right to request that we communicate protected health information to you by an alternate means or location other than your home address and telephone number. Your request must be made in writing to our contact person and must specify how or where you wish to be contacted. We will try to accommodate your request for alternate communications. If you request an alternate means of communication, that request should also be communicated by you to each of your physicians.


Restrictions: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information to a family member about a surgery you had. To request a restriction, you must make your request in writing to the listed contact person. We are not required to agree to your request. If we do agree, our agreement must be in writing, and we will comply with your request unless the information is needed to provide you with emergency treatment.

Additionally, you have the right to request that we not use or disclose your protected health information to a third party for purposes of payment or health care operations (not for treatment) if the information pertains solely to a healthcare item or service that has been paid for out-of-pocket and in full. Your request for a restriction must be submitted in writing to NeuroSynergy Associates. In this case, we must honor your request. However, you should be aware that such restrictions may have unintended consequences, particularly if other providers need to know that information (such as a pharmacy filling a prescription). It will be your obligation to notify any such other providers of this restriction. Additionally, such a restriction may impact your third party’s decision to pay for related care that you may not want to pay for out of pocket (and which would not be subject to the restriction).

Access: You have the right to review and obtain a copy of your health information, with certain exceptions. Usually, this includes medical and billing records but does not include psychotherapy notes. Your request to review or obtain a copy of your health information must be in writing to our listed contact person. You will be charged fees as authorized by law. To the extent your information is held in an electronic health record, you may be able to receive the information in an electronic format.

Amendment: If you feel that the health information we have about you is incorrect or incomplete, you have the right to ask for an amendment of that information. You have the right to request an amendment for as long as the information is kept by or for us. Your request for an amendment must be made in writing to our listed contact person, and include a reason that supports your request. We do not have to honor your request but will advise you of our decision in writing.

Accounting of Disclosures: You have the right to receive a list of certain disclosures of your protected health information that we have made within the last six years. Your request for an accounting must be in writing to our listed contact person and must state a time period for which you want an accounting. You may request one accounting free of charge within a 12-month period. A fee will be charged for additional lists within this same time period.

Breach Notification: In certain instances, you have the right to be notified in the event that we, or one of our Business Associates, discover an inappropriate use or disclosure of your protected health information. Notice of any such use or disclosure will be made in accordance with state and federal requirements.

Revisions of this Notice: We reserve the right to change this Notice, and the right to make the new provisions effective for all health information we currently maintain, as well as any information we receive in the future. If we make a major change to this Notice, the revised Notice will be posted in our place of business and on our website. In addition, a paper copy of the revised Notice will be available upon request.

To Report a Complaint: If you believe your protected health information privacy rights have been violated, you can file a complaint with us by mail, at the address provided in this Notice. You may also file a complaint with the Secretary of the United States Department of Health and Human Services, Office of Civil Rights, by completing a Health Information Privacy Complaint Form (available at: and sending it to the applicable OCR Regional Office listed on the form, or by calling 1-800-368-1019 for instructions and contact information. There will not be any penalty or retaliation against you for making a complaint to us or to the Department of Health and Human Services.

Copy of Notice: You have the right to a paper copy of this Notice. In addition, a copy of this Notice also may be obtained at our website,

Contact Person: If you have any questions or need information regarding our legal duties and privacy practices, or how to exercise any of your protected health information rights listed in this Notice, please contact:

NeuroSynergy Associates’ Compliance and Privacy
c/o Dr. Matthew Antonucci
8910 Astronaut Blvd, Suite 102, Cape Canaveral, FL, 32920

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