Notice of Privacy Practices

Effective date: [DATE]

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.

Template notice: This is starter language only and may not reflect all requirements that apply to your practice. Have a healthcare-experienced attorney or HIPAA compliance consultant review and customize this notice before publishing or providing it to patients. State laws may impose additional requirements.

Our pledge regarding your health information

We understand that health information about you and your health is personal. We are committed to protecting your health information. We are required by law to:

Maintain the privacy of protected health information ("PHI")
Provide you with this notice of our legal duties and privacy practices regarding your PHI
Notify you in the event of a breach of unsecured PHI
Follow the terms of the notice currently in effect

How we may use and disclose your health information

We may use and disclose PHI without your written authorization for the following purposes:

Treatment — to provide, coordinate, or manage your physical therapy and related services, including consulting with other healthcare providers involved in your care.
Payment — to bill you or, with your authorization, your insurance for the services we provide. This includes preparing superbills you submit for possible reimbursement.
Healthcare operations — for administrative functions such as quality assessment, staff training, and business planning.
As required by law — when required by federal, state, or local law (for example, public health reporting, court orders).

Other uses and disclosures

Other uses and disclosures of PHI not described in this notice will be made only with your written authorization. You may revoke an authorization at any time, in writing.

Your rights regarding your health information

You have the right to:

Inspect and copy your PHI in our records
Request an amendment to your PHI if you believe it is incorrect or incomplete
Receive an accounting of certain disclosures we have made of your PHI
Request restrictions on certain uses and disclosures of your PHI
Request that we communicate with you in a particular way or at a particular location
Receive a paper copy of this notice at any time

To exercise any of these rights, submit a written request to our Privacy Officer at the contact information below.

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. We will not retaliate against you for filing a complaint.

To file a complaint with us, contact our Privacy Officer using the information below.

To file a complaint with HHS, visit hhs.gov/hipaa/filing-a-complaint.

Changes to this notice

We may change this notice. The new notice will apply to all PHI we maintain. We will post the current notice on our website and provide a copy upon request.

Contact our Privacy Officer

Dr. Brian Calandra, PT, DPT — Privacy Officer
Ridgeline Performance Physical Therapy
Email: ridgelineperformancept@gmail.com
Phone: (978) 944-1711