NOTICE OF PRIVACY PRACTICES
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU
You have the following rights regarding health information we maintain about you:
INFORMATION ABOUT YOU
The following categories describe different ways that we may use and share your health information without further authorization.
For Treatment: We may use your personal health information to provide you with health care treatment or services. We may share your health information with doctors, nurses, health students, or other personnel who are involved in your care. 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 heath care professionals to assist in treating you.
For Payment: We may use and disclose your personal health Information to help us or another provider obtain payment for the healthcare services provided. For example, we may need to give your health plan information about your treatment session so your health plan will pay us or reimburse you for the service. 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 cost of treatment.
For Health Care Operations: We may use your health information to support our business practice activities and improve the quality and cost of 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 use your health information to contact you at the address and telephone number(s) you provide (including leaving a message at the telephone numbers) about scheduled or cancelled appointments, registration/insurance updates, billing and/or payment matters.
As Required by Law: We will disclose health information about you when required to do so by federal, state or local law. For example, your health information may be disclosed if we are required to report abuse, neglect, domestic violence or certain physical injuries.
To Avert a Serious Threat to Health or Safety: We may use and disclose your health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Military and Veterans: If you are a member of the military or a veteran, we may release your health information to the proper authorities so that they may carry out their duties under the law.
Workers Compensation: We may release health information about you for workers compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
Individuals Involved in Your Care or Payment for Your Care: If people such as family members, relatives or close personal friends are helping to care for you or helping to pay your medical bills, we may release health information to them. This is limited to the information necessary for your care or for payment for your care.
Public Health Risks: We may disclose information about you for public health activities, which generally include the following:
• To prevent or control disease, injury or disability
• To report reactions to medication or problems with products
• To notify people of recalls of products they may be using
• To notify person or organization required to receive information on FDA-regulated products 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 law enforcement officials:
• In reporting certain injuries, as required by law, gunshot wounds, burns, injuries to perpetrators of crime
• In response to a court order, subpoena, warrant, summons or similar process National Security and Intelligence Activities: We may release health information about you to an authorized federal official(s) for intelligence, counter-intelligence and other national security activities authorized by law.
Protective Services for the President and Others: We may disclose health information about you to authorized officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official.
Right to Inspect and Copy: Upon written request you have the right to inspect and copy health information that may be used to make decisions about your care. Usually this includes health and billing records. 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. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by our practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
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 theinformation. To request an amendment your request must be made in writing, submitted to the Privacy Officer, and must be contained to one page of paper legibly handwritten or typed. 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:
• 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 or for our practice
• Is not part of the information which you would be permitted to inspect and copy, or
• Is accurate and complete
Right to an Accounting of Disclosures: You have the right an accounting of any disclosures of your health information we have made, except for uses and disclosures related to treatment, payment, others with your permission and our health care operations, as previously described. To request this list of disclosures, you must submit your request in writing to the Privacy Officer. Your request must state a time period that may not be longer than six years. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions: You have a right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. For example, you could ask that we do not disclose information to your spouse regarding your treatment. Unless the request is to restrict disclosures to your health plan and you agree to pay out of pocket in full for all services provided, 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 emergency treatment. To request a restriction, you must make your request in writing to the Privacy Officer. In your request, you must tell us what information you want to limit and to whom you want the limits to apply.
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 Privacy Officer. 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.
Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice at any time. To obtain a copy please request it from the Clinic Front Office staff. This notice is also posted at our websites: www.performancePTSC.com
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 on the first page, the effective date. In addition each time you register for treatment or health care services, we will offer you a copy of the current notice in effect.
If you believe you privacy rights have been violated, you may file a complaint with us or with the Office of Civil Rights US Department of Health and Human Services. To file a complaint with either entity contact the Privacy Officer at Phone: 973.368.4907 All complaints must be submitted in writing. Filing a complaint will not affect the treatment or services you receive.
OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this notice or the laws that apply to use will be made only with your written authorization including disclosures that constitute the sale of your health information or disclosures related to marketing outside of face-to-face and promotional gifts of nominal value that are permitted under the law. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. 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 those we are required to retain our records of the care that we provided to you.
ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE
We will request that you sign a separate form or notice acknowledging you have received a copy of this notice. If you choose, or are not able to sign, a staff member will sign his/her name and date. This acknowledgement will be filed with your records.
Notice of Privacy Practices Effective Date: May 1, 2013 This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have questions about his notice, please contact our privacy officer: Phone: 973.368.4907
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.
We will also offer you a current copy of this notice each time you register for service. This notice is also posted on our website at: www.performancePTSC. com
OUR COMMITMENT TO YOUR PRIVACY
We are dedicated to maintaining the privacy of your medical information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law and our own procedures to:
• Maintain the confidentiality of your medical information.
• Provide you with this notice of our legal duties, commitment and privacy practices concerning your medical information.
• Follow the terms of our Notice of Privacy Practices that is currently in effect.
• Notify affected individuals of breaches of their unsecured protected health information.