Statement of Privacy Notice
Form and Function Physical Therapy
Statement of Privacy Notice
Effective June 1, 2003
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.
We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations.
We may disclose your health information to your insurance provider for the purpose of payment or health care operations.
We may disclose your health information as necessary to comply with State Workers’ Compensation Laws.
We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.
As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.
We may disclose your health information in the course of any administrative or judicial proceeding.
We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.
We may disclose your health information to coroners or medical examiners.
We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.
We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.
It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.
We may disclose your health information for military, national security, prisoner and government benefits purposes. We may leave a message on an automated answering device or person answering the phone for the purposes of scheduling appointments. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment.”
We may contact you by phone, mail, or email. “It is our practice to participate in charitable and marketing events to raise awareness, food donations, gifts, money, etc. During these times, we may send you a letter, post card, invitation or call your home to invite you to participate in the charitable activity.
In the event that we are sold or merged with another organization, your health information/record will become the property of the new owner.
¾ You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that we are not required to agree to the restriction that you requested.
¾ You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.
¾ You have the right to inspect and copy your health information.
¾ You have a right to request that we amend your protected health information. Please be advised, however, that we are not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.
¾ You have a right to receive an accounting of disclosures of your protected health information made by us.
¾ You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.
We reserve the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, we are required by law to comply with this Notice.
We are required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact us by calling this office at (999) 999-9999. If our Privacy Officer is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.
Complaints about your Privacy rights, or how we have handled your health information should be directed to our Privacy Officer by calling this office at (999) 999-9999. If our Privacy Officer is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.
If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:
DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
I have read the Privacy Notice and understand my rights contained in the notice.
By way of my signature, I provide the company above with my authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice
Patient’s Name (print)
Patient’s Signature Date
Authorized Facility Signature Date