Hippa Notice of Privacy Practices


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Notice of Privacy Practices for Protected Health Information

Patty Pennell MSPT Inc. dba Back to Motion


Effective date: December 2011

The Practice of Patty Pennell MSPT Inc. dba Back to Motion is required by applicable federal and state laws to maintain the privacy of your health information. Protected health information (PHI) is the information we create and maintain in providing our services to you. Such information may include documentation of your symptoms, examination and test results, diagnoses and treatment protocols. It also may include billing documents for those services. We are permitted by federal privacy law, the Health Insurance Portability & Accountability Act of 1996 (HIPAA), to use and disclosure your PHI for the purposes of treatment, payment, and health care operations without your written authorization.

Examples of Uses of Your Health Information for Treatment Purposes are:

·          Our physical therapists (PT) and physical therapist assistants (PTA) obtain treatment information about you and record it in a health record.

·          During the course of your treatment, if the PT determines he/she will need to consult with a specialist in another area, he/she will share the information with the specialist and obtain his/her input.

·          We may contact you by phone, at your home, if we need to speak to you about a medical condition, or to remind you of medical appointments.

Example of a Use of Your Health Information for Payment Purposes:

·          We submit requests for payment to your health insurance company; the health insurance company requests information from us regarding medical care provided to you. We will provide this information to them.

Example of a Use of Your Information for Health Care Operations:

·          We may use or disclose your PHI in order to conduct certain business and operational activities such as quality assessment activities, to review employee activities, or to assist in the training of students. We may share information about you with our business associates, who perform these functions on our behalf, as necessary to obtain these services.

Other Examples:

·          We may use or disclose your PHI to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use or disclose your PHI for activities such as sending you a newsletter about our practice and the services we offer. You may contact us to request that these materials not be sent to you.

Other uses and disclosure of your PHI will only be made with your authorization, unless otherwise permitted or required by law, as described below.

Your Health Information Rights

The health and billing records we maintain are the physical property of the office. The information in them, however, belongs to you. You have a right to:

·          Request a restriction on certain uses and disclosures of your health information. We are not required to grant the request, but we will comply with any request that we agree to grant;

·          Obtain a paper copy of the current Notice of Privacy Practices for Protected Health Information (“the Notice”) by making a request at our office;

·          Request that you be allowed to inspect and copy your health record and billing record – you may exercise this right by delivering the request to our office;

·          Appeal a denial of access to your protected health information, except in certain circumstances;

·          Request that your health care record be amended to correct incomplete or incorrect information by delivering a request to our office. We may deny your request if you ask us to amend information that either was not created by us (unless the person or entity that created the information is no longer available to make the amendment), is not part of the health information kept by the office, is not part of the information that you would be permitted to inspect and copy, or is accurate and complete. If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be placed in your record;

·          Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office;

·          Restrict information going to your health plan about an item or service for which you pay the Practice out-of-pocket and in full for the item or service.

·          Obtain an accounting of disclosures of your health information as required to be maintained by law. An accounting will not include uses and disclosures of information for treatment, payment, or operations; disclosures or uses made to you or made at your request; uses or disclosures made pursuant to an authorization signed by you; uses or disclosures made in a facility directory or to family members or friends relevant to that person’s involvement in your care or in payment for such care; or, uses or disclosures to notify family or others responsible for your care of your location, condition, or your death.

·          Revoke authorizations that you made previously to use or disclose information by delivering a written revocation to our office (except to the extent action has already been taken based on a previous authorization).

Our Responsibilities: The office is required to

·          Maintain the privacy of your health information as required by law;

·          Provide you with a notice (‘Notice’) as to our duties and privacy practices regarding the information we collect and maintain about you;

·          Abide by the terms of this Notice;

·          Notify you if we cannot accommodate a requested restriction or request; and,

·          Accommodate your reasonable requests regarding methods to communicate health information with you and not disclose PHI to your health plan if you request that we do not, and pay for the item/service out-of-pocket and in full. You must request this Patient Right in writing.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and to enact new provisions regarding the PHI we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy, visiting our website, or by visiting our office and picking up a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, or would like to report a problem regarding the handling of your information, you may contact the Privacy Officer. If you believe your privacy rights have been violated, you may file a complaint by delivering it in writing to the Practice’s Privacy Officer. You may also file a complaint with the Secretary of Health and Human Services, Office for Civil Rights (OCR). The address for this office is: OCR – U.S. Department of Health and Human Services – 200 Independence Avenue S.W. – Room 509F, HHH Building – Washington, D.C. 20201. Information regarding the steps to file a complaint with the OCR can also be found at: www.hhs.gov/ocr/privacy/hipaa/complaints.

·          We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the office.

l; mso-list: l0 level1 lfo7; mso-layout-grid-align: none; text-autospace: none;”>·          We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.

Other Uses and Disclosures of your PHI

Communication with Family: Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object, or in an emergency.

Notification: Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Research: We may disclose 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.

Disaster Relief: We may use and disclose your protected health information to assist in disaster relief efforts.

Food and Drug Administration (FDA): We may disclose to the FDA your PHI relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workers’ Compensation: If you are seeking compensation through Workers Compensation, we may disclose your PHI to the extent necessary to comply with laws relating to Workers Compensation.

Public Health: As authorized by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition.

Abuse & Neglect: We may disclose your PHI to public authorities as allowed by law to report abuse or neglect.

Employers: We may release health information about you to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness or injury. In such circumstances, we will give you written notice of such release of information to your employer. Any other disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer.

Enforcement: We may disclose your PHI for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecution, or to the extent an individual is in the custody of law enforcement.

Health Oversight: Federal law allows us to release your PHI to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings: We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order.

Serious Threat: To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

For Specialized Governmental Functions: We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Other Uses: Other uses and disclosures, besides those identified in this Notice, will be made only as otherwise required by law or with your written authorization. You may revoke any authorization at any time, as previously provided in this Notice under “Your Health Information Rights.”

Website: You are able to access our Notice electronically on our website: backtomotion.net.


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