Effective Date: 3/13/2017
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
If you have any questions about this notice, please contact our privacy officer:
111 Deerwood Rd., ste 240, San Ramon CA 94583
1. Summary of Rights and Obligations Concerning Health Information. Ironhorse Physical Therapy and Pilates Inc. is committed to preserving the privacy and confidentiality of your health information, which is required both by federal and state law. We are required by law to provide you with this notice of our legal duties, your rights, and our privacy practices, with respect to using and disclosing your health information that is created or retained by Ironhorse Physical Therapy and Pilates Inc. .Each time you visit us, we make a record of your visit. Typically, this record contains your symptoms, examination and test results, our assessment of your condition, a record of your treatment interventions, and a plan for future care or treatment. We have an ethical and legal obligation to protect the privacy of your health information, and we will only use or disclose this information in limited circumstances. In general, we may use and disclose your health information to:
known as health care operations;
We may also use or disclose your health information where you have authorized us to do so.
Although your health record belongs to Ironhorse Physical Therapy and Pilates Inc. , the information in your record belongs to you. You have the right to:
disclosure of your health information; and
We are required to:
respect to information we collect and maintain about you;
We reserve the right to change our practices and to make the new provisions effective for all your health information that we maintain.
Should our information practices change, a revised Notice of Privacy Practices will be available upon request. If there is a material change, a revised Notice of Privacy Practices will be distributed to the extent required by law. We will not use or disclose your health information without your authorization, except as described in our most current Notice of Privacy Practices. In the following pages, we explain our privacy practices and your rights to your health information in more detail.
2. We may use or disclose your medical information in the following ways:
• in response to a court order, subpoena, warrant, summons, or similar process of authorized under state or federal law;
• to identify or locate a suspect, fugitive, material witness, or similar person;
• about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’sagreement;
• about a death we believe may be the result of criminal conduct;
• about criminal conduct at [name of provider];
• to coroners or medical examiners;
• in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime;
• to authorized federal officials for intelligence, counterintelligence, and other national security authorized by law;and
• to authorized federal officials so they may conduct special investigations or provide protection to the President, other authorized persons, or foreign heads of state.
3. Authorization for Other Uses of Medical Information. Uses of medical information not covered by our most current Notice of Privacy Practices or the laws that apply to us will be made only with your written authorization. You should be aware that we are not responsible for any further disclosures made by the party you authorize us to release information to. If you provide us with authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization, except to the extent that we have already taken action in reliance on your authorization or, if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has the right to contest a claim or the insurance coverage itself. We are unable to take back any disclosures we have already made with your authorization, and we are required to retain our records of the care that we provided to you.
4. Your Health Information Rights. You have the following rights regarding medical information we gather about you:
A. Right to Obtain a Paper Copy of This Notice. You have the right to a paper copy of this Notice of Privacy Practices at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy.
B. Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes medical and billing records.
To inspect and copy medical information, you must submit a written request to your provider. If you request a copy of your medical information, we may, subject to state law restrictions or limitations, charge a reasonable fee for the costs of labor, postage, and supplies associated with your request. We may not charge you a fee if you require your medical information for a claim for benefits under the Social Security Act (such as claims for Social Security, Supplemental Security Income, and any other state or federal needs-based benefit program.
If your medical information is maintained in an electronic health record, you also have the right to request that an electronic copy of your record be sent to you or to another individual or entity. We may charge you a reasonable cost based fee limited to the labor costs associated with transmitting the electronic health record.
C. Right to Amend. If you feel that medical 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 retain the information.
To request an amendment, your request must be made in writing and submitted to your provider. In addition, you must provide a reason that supports your request. 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:
If we deny your request for amendment, you may submit a statement of disagreement. We may reasonably limit the length of this statement. Your letter of disagreement will be included in your medical record, but we may also include a rebuttal statement.
D. Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures of your health information made by us. In your accounting, we are not required to list certain disclosures, including:
to treatment, payment, and health care operations, however, if the disclosures were made through an electronic
health record, you have the right to request an accounting for such disclosures that were made during the
previous 3 years;
• disclosures made directly to you.
To request an accounting of disclosures, you must submit your request in writing to your provider or privacy officer. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you would like the accounting of disclosures (for example, on paper or electronically by e-mail). The first accounting of disclosures you request within any 12 month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting of disclosures. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time, before any costs are incurred. Under limited circumstances mandated by federal and state law, we may temporarily deny your request for an accounting of disclosures.
E. Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. If you paid out-of-pocket for a specific item or service, you have the right to request that medical information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we are required to honor that request unless we are required by law to disclose the information. You also have the right to request a limit on the medical information we communicate about you to someone who is involved in your care or the payment for your care.
Except as noted above, we are not required to agree to your request. If we do agree, we will comply with your request unless the restricted information is needed to provide you with emergency treatment. To request restrictions, you must make your request in writing to your provider or privacy officer. In your request, you must tell us:
F. Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by e-mail. To request confidential communications, you must make your request in writing to your provider. 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.
G. Right to Receive Notice of a Breach. We are required to notify you by first class mail or by e-mail (if you have indicated a preference to receive information by e-mail), of any breaches of Unsecured Protected Health Information as soon as possible, but in any event, no later than 60 days following the discovery of the breach. “Unsecured Protected Health Information” is information that is not secured through the use of a technology or methodology identified by the Secretary of the U.S. Department of Health and Human Services to render the Protected Health Information unusable, unreadable, and undecipherable to unauthorized users.
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. To file a complaint with us, contact our privacy officer at the address listed above. All complaints must be submitted in writing and should be submitted within 180 days of when you knew or should have known that the alleged violation occurred. See the Office for Civil Rights website, www.hhs.gov/ocr/hipaa/ for more information. You will not be penalized for filing a complaint.