Notice of Privacy Practices

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.

INTRODUCTION

At Premier Performance and Physical Therapy, we are committed to treating and protecting

your medical information. The creation of a medical record detailing the care and services you

receive helps us provide you with quality health care.

This Notice of Privacy Practices describes how we may use and disclose your protected health

information to carry out treatment, payment or health care operations and for other purposes

that are permitted or required by law. It also describes your rights to access and control your

protected health information. “Protected health information” is information about you,

including demographic information, that may identify you and that relates to your past, present

or future physical or mental health or condition and related health care services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the

terms of our notice, at any time. The new notice will be effective for all protected health

information that we maintain at that time. Upon your request, we will provide you with any

revised Notice of Privacy Practices. You may request a revised version by accessing our website,

or calling the office and requesting that a revised copy be sent to you in the mail or asking for

one at the time of your next appointment.

1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your physical therapist, our

office staff and others outside of our office who are involved in your care and treatment for

providing health care services to you. Your protected health information may also be used and

disclosed to pay your health care bills and to support the operation of your physical therapist’s

practice.

Following are examples of the types of uses and disclosures of your protected health

information that your physical therapist’s office is permitted to make. These examples are not

meant to be exhaustive, but to describe the types of uses and disclosures that may be made by

our office.

Treatment: We will use and disclose your protected health information to provide, coordinate,

or manage your health care and any related services. This includes the coordination or

management of your health care with another provider. For example, we would disclose your

protected health information, as necessary, to a home health agency that provides care to you.

We will also disclose protected health information to other physicians who may be treating you.

For example, your protected health information may be provided to a physician to whom

you have been referred to ensure that the physician has the necessary information to diagnose

or treat you. In addition, we may disclose your protected health information from time-to-time

to another physician or health care provider (e.g., a specialist or laboratory) who, at the request

of your physician, becomes involved in your care by providing assistance with your health care

diagnosis or treatment to your physician.

Payment: Your protected health information will be used and disclosed, as needed, to obtain

payment for your health care services provided by us or by another provider. This may include

certain activities that your health insurance plan may undertake before it approves or pays for

the health care services we recommend for you such as: making a determination of eligibility or

coverage for insurance benefits, reviewing services provided to you for medical necessity, and

undertaking utilization review activities. For example, obtaining approval for a hospital stay

may require that your relevant protected health information be disclosed to the health plan to

obtain approval for the hospital admission.

Health Care Operations: We may use or disclose, as needed, your protected health information

to support the business activities of your physical therapist’s practice. These activities include,

but are not limited to, quality assessment activities, employee review activities, training of

medical students, licensing, fundraising activities, and conducting or arranging for other

business activities.

We will share your protected health information with third party “business associates” that

perform various activities (for example, billing or transcription services) for our practice.

Whenever an arrangement between our office and a business associate involves the use or

disclosure of your protected health information, we will have a written contract that contains

terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with

information about treatment alternatives or other health-related benefits and services that

may be of interest to you. You may contact our Privacy Officer to request that these materials

not be sent to you.

We may use or disclose your demographic information and the dates that you received

treatment from your physical therapist, as necessary, to contact you for fundraising activities

supported by our office. If you do not want to receive these materials, please contact Premier

Performance and Physical Therapy to request that these fundraising materials not be sent to

you.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your

Authorization or Opportunity to Agree or Object:We may use or disclose your protected health

information in the following situations without

your authorization or providing you the opportunity to agree or object. These situations

include:

Required By Law: We may use or disclose your protected health information 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 uses or disclosures.

Public Health: We may disclose your protected health information for public health activities

and purposes to a public health authority that is permitted by law to collect or receive the

information. For example, a disclosure may be made for the purpose of preventing or

controlling disease, injury or disability.

Communicable Diseases: We may disclose your protected health information, if authorized by

law, to a person who may have been exposed to a communicable disease or may otherwise be

at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose protected health information to a health oversight agency

for activities authorized by law, such as audits, investigations, and inspections. Oversight

agencies seeking this information include government agencies that oversee the health care

system, government benefit programs, other government regulatory programs and civil rights

laws.

Abuse or Neglect: We may disclose your protected health information to a public health

authority that is authorized by law to receive reports of child abuse or neglect. In addition, we

may disclose your protected health information if we believe that you have been a victim of

abuse, neglect or domestic violence to the governmental entity or agency authorized to receive

such information. In this case, the disclosure will be made consistent with the requirements of

applicable federal and state laws.

Food and Drug Administration: We may disclose your protected health information to a person

or company required by the Food and Drug Administration for the purpose of quality, safety, or

effectiveness of FDA-regulated products or activities including, to report adverse events,

product defects or problems, biologic product deviations, to track products; to enable product

recalls; to make repairs or replacements, or to conduct post marketing surveillance, as

required.

Legal Proceedings: We may disclose protected health information in the course of any judicial

or administrative proceeding, in response to an order of a court or administrative tribunal (to

the extent such disclosure is expressly authorized), or in certain conditions in response to a

subpoena, discovery request or other lawful process.Law Enforcement: We may also disclose

protected health information, so long as applicable

legal requirements are met, for law enforcement purposes. These law enforcement purposes

include (1) legal processes and otherwise required by law, (2) limited information requests for

identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that

death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the

premises of our practice, and (6) medical emergency (not on our practice’s premises) and it is

likely that a crime has occurred.

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health

information to a coroner or medical examiner for identification purposes, determining cause of

death or for the coroner or medical examiner to perform other duties authorized by law. We

may also disclose protected health information to a funeral director, as authorized by law, in

order to permit the funeral director to carry out their duties. We may disclose such information

in reasonable anticipation of death. Protected health information may be used and disclosed

for cadaveric organ, eye or tissue donation purposes.

Research: We may disclose your protected health information to researchers when their

research has been approved by an institutional review board that has reviewed the research

proposal and established protocols to ensure the privacy of your protected health information.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your

protected health information, if we believe that the use or disclosure is necessary to prevent or

lessen a serious and imminent threat to the health or safety of a person or the public. We may

also disclose protected health information if it is necessary for law enforcement authorities to

identify or apprehend an individual.

Military Activity and National Security: When the appropriate conditions apply, we may use or

disclose protected health information of individuals who are Armed Forces personnel (1)for

activities deemed necessary by appropriate military command authorities; (2) for the purpose

of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3)

to foreign military authority if you are a member of that foreign military services. We may also

disclose your protected health information to authorized federal officials for conducting

national security and intelligence activities, including for the provision of protective services to

the President or others legally authorized.

Workers’ Compensation: We may disclose your protected health information as authorized to

comply with workers’ compensation laws and other similar legally- established programs.

Inmates: We may use or disclose your protected health information if you are an inmate of a

correctional facility and your physical therapist created or received your protected health

information in the course of providing care to you.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization:

Other uses and disclosures of your protected health information will be made only with your

written authorization, unless otherwise permitted or required by law as described below. You

may revoke this authorization in writing at any time. If you revoke your authorization, we will

no longer use or disclose your protected health information for the reasons covered by your

written authorization. Please understand that we are unable to take back any disclosures

already made with your authorization.

Other Permitted and Required Uses and Disclosures That Require Providing You the

Opportunity to Agree or Object:

We may use and disclose your protected health information in the following instances. You

have the opportunity to agree or object to the use or disclosure of all or part of your protected

health information. If you are not present or able to agree or object to the use or disclosure of

the protected health information, then your physical therapist may, using professional

judgment, determine whether the disclosure is in your best interest.

Facility Directories: Unless you object, we will use and disclose in our facility directory your

name, the location at which you are receiving care, your general condition (such as fair or

stable), and your religious affiliation. All of this information, except religious affiliation, will be

disclosed to people that ask for you by name. Your religious affiliation will be only given to a

member of the clergy, such as a priest or rabbi.

Others Involved in Your Health Care or Payment for your Care: Unless you object, we may

disclose to a member of your family, a relative, a close friend or any other person you identify,

your protected health information that directly relates to that person’s involvement in your

health care. If you are unable to agree or object to such a disclosure, we may disclose such

information as necessary if we determine that it is in your best interest based on our

professional judgment. We may use or disclose protected health information to notify or assist

in notifying a family member, personal representative or any other person that is responsible

for your care of your location, general condition or death. Finally, we may use or disclose your

protected health information to an authorized public or private entity to assist in disaster relief

efforts and to coordinate uses and disclosures to family or other individuals involved in your

health care.

2. YOUR RIGHTS

Following is a statement of your rights with respect to your protected health information and a

brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information. This means you may

inspect and obtain a copy of protected health information about you for so long as we maintain

the protected health information. You may obtain your medical record that contains medical

and billing records and any other records that your physical therapist and the practice uses

formaking decisions about you. As permitted by federal or state law, we may charge you a

reasonable copy fee for a copy of your records.

Under federal law, however, you may not inspect or copy the following records: psychotherapy

notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or

administrative action or proceeding; and laboratory results that are subject to law that

prohibits access to protected health information. Depending on the circumstances, a decision

to deny access may be reviewable. In some circumstances, you may have a right to have this

decision reviewed. Please contact our Privacy Officer if you have questions about access to your

medical record.

You have the right to request a restriction of your protected health information. This means

you may ask us not to use or disclose any part of your protected health information for the

purposes of treatment, payment or health care operations. You may also request that any part

of your protected health information not be disclosed to family members or friends who may

be involved in your care or for notification purposes as described in this Notice of Privacy

Practices. Your request must state the specific restriction requested and to whom you want the

restriction to apply.

Your physical therapist is not required to agree to a restriction that you may request. If your

physical therapist does agree to the requested restriction, we may not use or disclose your

protected health information in violation of that restriction unless it is needed to provide

emergency treatment. With this in mind, please discuss any restriction you wish to request with

your physical therapist. You may request a restriction by providing the request in writing to

Premier Performance and Physical Therapy.

You have the right to request to receive confidential communications from us by alternative

means or at an alternative location. We will accommodate reasonable requests. We may also

condition this accommodation by asking you for information as to how payment will be handled

or specification of an alternative address or other method of contact. We will not request an

explanation from you as to the basis for the request. Please make this request in writing to

Premier Performance and Physical Therapy.

You may have the right to have your physical therapist amend your protected health

information. This means you may request an amendment of protected health information

about you in a designated record set for so long as we maintain this information. In certain

cases, we may deny your request for an amendment. If we deny your request for amendment,

you have the right to file a statement of disagreement with us and we may prepare a rebuttal

to your statement and will provide you with a copy of any such rebuttal. Please contact Premier

Performance and Physical Therapy if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your

protected health information. This right applies to disclosures for purposes other than

treatment, payment or health care operations as described in this Notice of Privacy Practices.

It excludes disclosures we may have made to you if you authorized us to make the disclosure, for

a facility directory, to family members or friends involved in your care, or for notification

purposes, for national security or intelligence, to law enforcement (as provided in the privacy

rule) or correctional facilities, as part of a limited data set disclosure. You have the right to

receive specific information regarding these disclosures that occur. The right to receive this

information is subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have

agreed to accept this notice electronically.

3. COMPLAINTS

You may complain to us or to the Secretary of Health and Human Services if you believe your

privacy rights have been violated by us. You may file a complaint with us by notifying our

Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.

If you have any questions about the complaint process or require additional information, please

contact Premier Performance and Physical Therapy at 407-720-4236 or at

PremierPerformPT@gmail.com.

4. RIGHT TO PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES

Our practice 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 authorization. Please note: we are required to retain records of your care.

Again, if you have any questions regarding this Notice or our health information privacy

policies, please contact Premier Performance and Physical Therapy at 407-720-4236 or at

PremierPerformPT@gmail.com