HIPPA Notice of Privacy Practices

Effective Date: April 14, 2003

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY. THIS FORM IS FOR USE WHEN SUCH AUTHORIZATION IS REQUIRED AND COMPLIES WITH THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACOR OF 1996 (HIPPA) PRIVACY STANDARDS. 

This notice describes Looking Ahead Pediatric Physical Therapy, PLLC privacy practices and how medical information about you may be used or disclosed and how you can obtain access to the information. In addition, all of our locations may share health information with each other for treatment, payment, or health care operational purposes described in this notice. All other uses and disclosures of health information for treatment, payment, or health care operational purposes not described in this Notice will be made only with authorization from you.

OUR PLEDGE REGARDING HEALTH INFORMATION:

Looking Ahead Pediatric Physical Therapy, PLLC understand that health information about you and your health care is personal, and we are committed to protecting your health information. We are required by federal and state laws to maintain the privacy of your Protected Health Information (PHI) and to give you this notice explaining our privacy practices regarding that information. Looking Ahead Pediatric Physical Therapy, PLLC creates a record of the care and services you receive from us. This information is recorded to provide you with quality care and to comply with certain legal requirements. This notice applies to all records of your care generated by this health care practice, whether made by your therapist or others working in this office. This notice will inform you of the way we may use and disclose health information about you. This notice also outlines your rights to your health information, and describes certain obligations Looking Ahead Pediatric Physical Therapy, PLLC has regarding the use and disclosure of your health information.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that we use and disclose health information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment: We may use health information about you to provide you with health care treatment or services. We may disclose health information about you to doctors, nurses, technicians, health students, or other personnel who are involved in treatment of your health. This includes the coordination or management of your health care with a third party. For example, information obtained by a physical therapist or other health care practitioner will be recorded in your record and will be used to determine your plan of care. This information may be provided to your physician or other health care professionals to assist in treating you.

For Payment: We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about your office visit so your health plan will pay us or reimburse you for the visit. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

 For Health Care Operations: We may use health information about you for operations of our health care practice. These uses are necessary to run our practice and ensure that all of our patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements.

 As Required By Law: We will disclose health information about you when required to do so by federal, state, or local law.

Marketing and any purposes, which require the sale of your information: These disclosures require your written authorization.

To Avert a Serious Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person as mandated by local statute. Any disclosure, however, would only be to someone able to help prevent the threat.

 Public Health Risks: We may disclose health information about you for public health activities as mandated by local statute.

Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

 Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

 Law Enforcement: We may release health information if asked to do so by a law enforcement official, as mandated by local statute.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU:

 You have the following rights regarding health information we maintain about you:

 Right to Inspect and Copy: You have the right to inspect and copy your PHI that may be used to make decisions about your care. Usually, this includes health and billing records. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to Looking Ahead Pediatric Physical Therapy, PLLC. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with your request.

The Right to an Electronic Copy of Electronic Medical Records: You have the right to request a copy of your electronic medical records to be given to you and/or have transmitted to another individual or entity. We will make every effort to provide the electronic copy in the format you request however it is not readily available but us we will provide it in either our standard format or in hard copy form (fees may apply).

 Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information. To request an amendment, your request must be made in writing and submitted to us. In addition, you must provide a reason that supports your request for an amendment. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: is not part of the health information kept by or for our practice; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete. Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

 Right to Request Restrictions: You have the right to request a restriction or limitation on the 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 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 restrict a specified health care professional from use of your information, or that we not disclose information to your spouse about treatment you received. We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must make your request in writing to us. In your request, you must list the information you want to limit and to whom you want the limits to apply, for example, use of any information by a specified health care employee, or disclosure of specified treatment to your spouse.

 Right to Request Confidential Communications: You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail to a post office box. To request confidential communications, you must make your request in writing to the Medical Records Coordinator. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. If there is a specific healthcare provider that you do not want us to share your health care information and medical records with, we require written notification. Otherwise, we will communicate with the health care providers and legal guardians/parents who are involved in the patient’s direct care. 

 Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice at any time.

Breach Notification: You have the right to be notified in the event Looking Ahead Pediatric Physical Therapy, PLLC determines that a breach of your unsecured personal health information has occurred.

 Fundraising: We generally do not participate in fundraising with our patient information. If Looking Ahead Pediatric Physical Therapy, PLLC were to participate in fundraising activity, you have the right to opt-out of any communications to you for fundraising purposes.

 Restrictions on Disclosures to Your Health Plan: The Authorized Party, Looking Ahead Pediatric Physical Therapy, PLLC has my authorization to disclose Medical Records, including but not limited to progress notes, evaluations to: Any party that is approved by the Authorized Party, including but not limited to your child's medical team/pediatrician of record, TEIS, Orthopedic Medicine, Neurology, Ophthalmology, Chiropractic, other therapeutic agencies, etc. You have the right to request a restriction on certain disclosures to your health plan if the disclosure is purely for carrying out payment or health care operations and the requested restriction is for services paid out-of-pocket. I understand that it is possible that Medical Records and information used or disclosed with my permission may be re-disclosed by a recipient and no longer protected by the HIPAA Privacy Standards.

 Revocation: You may revoke the authorization at any time by submitting a written revocation and we will no longer disclose your PHI. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

CHANGES TO THIS NOTICE:

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility. The notice will contain the effective date on the first page.

 COMPLAINTS:

If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services Office for Civil Rights. To file a complaint with us, contact the HIPAA Privacy Officer at (615) 373-1350. There will be no retaliation against you for filing a complaint.

 TERMINATION: This authorization will terminate upon written request to Looking Ahead Pediatric Physical Therapy, PLLC by the patient, if minor, the parent or legal guardian

If you have any questions about this notice, please contact Looking Ahead Pediatric Physical Therapy, PLLC at 615-784-8104 or info@lookingaheadpt.com