Artemis Physical Therapy, PLLC
P.O. Box 164
Westport, NY 12993
Tel: (518) 302-1780
NOTICE OF PRIVACY PRACTICES
EFFECTIVE: September 2020
THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND/OR DISCLOSED. IT ALSO EXPLAINS HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS DOCUMENT CAREFULLY.
This practice is required by the Health Insurance Portability and Accountability Act (“HIPAA”) to develop and maintain the privacy of your protected health information (“PHI”). This notice describes the practice’s legal responsibilities and privacy practices with respect to your protected health information as well as your rights regarding our use and disclosure of your protected health information. This practice is required to abide by the terms of this Notice of Privacy Practices currently in effect. If you have questions about any of the information provided in this notice or if you would like further information about the privacy practices, please let me know.
This practice is required to maintain both the privacy and the security of your protected health information. In the event that a breach occurs involving your unsecured health information, this practice will inform you promptly that such health information may have been compromised. Your health information will not be used or shared by this practice other than as described here in this Notice of Privacy Practices or with your written consent to use or share such information. Your written consent may be revoked at any time; however, such revocation must be done in writing.
You may request a copy of this Notice of Privacy Practices at any time.
I. Health Information Rights
You have certain rights when it comes to your protected health information. These rights are explained below.
1. Right to Inspect and/or Receive Copies of your Health Information
You, or your legally authorized representative, have the right to inspect and/or obtain a copy of your health records, including those records about you kept in written and/or electronic format. A request to inspect and/or obtain a copy of your health records must be made in writing. There may be a reasonable fee for the costs of copying, mailing, or any other supplies used to fulfill your request for records.
This practice will provide a copy or a prepared summary of your health information within fifteen (15) days of your request. If this practice needs additional time to respond to your request, this practice will notify you in writing within fifteen (15) days and will provide an explanation for the delay and the expected duration of the delay.
This practice may deny your request for records in certain circumstances. In the event that your request for records is denied, this practice may provide you with a prepared summary of the requested health information and a written explanation for the denial of such records. This practice may also deny part of your record request, in which case this practice will provide you access to the other parts of your record that you have not been denied access to. Any denial of a record request will include the process by which you may appeal the denial.
2. Right to Request to Amend Your Records
You may ask this practice to correct health information about you that you believe is incorrect or incomplete. A request to correct your health information must be made in writing and the amendment to your health information must be kept in our records.
This practice may deny your request to make an amendment to your health information within sixty (60) days, or longer if you are notified. In the event that your request to make an amendment to your health information is denied, this practice will provide you with written notice and a written explanation for the denial no later than sixty (60) days, absent an extension. If you disagree with the denial for amendment, you may submit a written statement explaining your disagreement and this practice will place a copy of such statement in your records.
3. Request Confidential Communications
For confidentiality purposes, you may ask this practice to contact you in a specific way or at alternate locations. For example, you may request that this practice contact you at a specific telephone number or at an alternative mailing address. Such a request must be made in writing. This practice will try to accommodate all reasonable requests.
4. Request to Limit the Health Information that we Use or Share
You may request that this practice not use or share certain health information for treatment, payment, or health care operations. Such a request must be made in writing and it must include: (1) the information that you would like to limit; (2) how you would like to limit the use of your information; and (3) to whom you would like these limitations to apply. This practice is not required to agree to this request, and we may deny the request if it would affect your care and treatment. If this practice agrees to your request to limit the use or sharing of your health information, you may revoke these restrictions at any time.
As stated above, this practice is not required to agree to your request for a restriction on the use or sharing of your health information, unless the request is for payment purposes and you have paid the provided services out of pocket. The exception to this is if the disclosure of your health information is required by law. We will follow this request unless a law requires us to share your information.
5. Request an Accounting of Disclosures
You may ask for an accounting (a list) of who this practice has shared your health information with for the last six (6) years prior to the date of your request for such an accounting. This accounting will contain who this practice shared your health information with, and why your health information was shared.
An accounting of disclosures will contain all disclosures made, except those made for treatment, payment, health care operations, and disclosures that you asked this practice to make. We may charge a reasonable, cost-based fee for an accounting of disclosures.
6. Right to Choose Someone to Act on Your Behalf
You have the right to give someone a medical power of attorney so that they can exercise your rights and make choices about your information on your behalf. A legal guardian may also exercise these rights. Prior to this practice taking any action, we will ensure that any individual looking to act on your behalf has the legal authority to do so.
7. Right to Request a Copy of this Notice of Privacy Practices
You may request a paper or an electronic copy of this Notice of Privacy Practices. To receive either an electronic or a paper copy, please contact Dana Taussig. Dana Taussig may also give you a more detailed explanation of your rights.
II. How We May Use or Disclose Your Health Information
1. Treatment, Payment, and Health Care Operations
This practice typically uses or shares your health information in the following ways:
Treatment. With your consent, this practice may share your health information with other health care providers who are treating you. Your health information can be shared to the extent necessary to treat or diagnose a medical condition. Additionally, this practice may share your health information with other health care practitioners that need to know such information with respect to your treatment outside of this practice.
Payment. With your consent, this practice may share your health information to bill for services provided, obtain and collect payment, for eligibility verification, preauthorization, ongoing authorization from other provider, agencies, and insurance companies. Your health information may be shared with Medicaid and Medicare administrations in connection with reimbursement claims, as appropriate.
Health Care Operations. With your consent, this practice may use your health information for matters of quality improvement, general administration, business planning and management, legal and auditing services, and licensing and accreditation.
To Keep you Informed. Unless you provide this practice with alternative instructions, this practice may contact you about reminders for treatment.
2. Notification and Communication with Family
In certain circumstance, you can advise this practice of your choices about what health information the practice shares. You have the right and the choice to tell this practice to disclose your health information to a family member, to a personal friend, or to any other person identified to this practice by you, provided that you are present, or otherwise available prior to the disclosure, you have the capacity to make your own health care decisions, and you have been given the opportunity to object to the disclosure and have not done so. If you cannot tell us your preference, for example, if you are unconscious, this practice may go ahead and share your information if it is believed that it is in your best interest to do so. This practice may disclose your health information in order to notify or assist in notifying a family member, your personal representative, or another person responsible for your care about your location, your general condition, or in the event of your death. If you are available to agree or object, this practice will give you the opportunity to object to this notification. If you are unable or unavailable to agree or object, this practice will use its best judgment in communication with your family and others. This practice may also share your information when needed to lessen a serious and imminent threat to health or safety.
3. Medical Emergencies
This practice may share your health information without your consent to the extent necessary to meet a bona fide medical emergency in which your informed consent cannot be obtained. Any such disclosure of your health information must be documented by this practice.
4. Public Health and Safety
This practice may share your health information for certain public health and safety situations. These situations include:
- Preventing or controlling disease, injury, or disability;
- Reporting adverse reactions to medications;
- Reporting suspected abuse, neglect, or domestic violence; or
- Preventing or reducing a serious threat to anyone’s health or safety.
5. Permitted by Law
Deceased person information. This practice may disclose your health information to coroners, medical examiners, and funeral directors.
Worker’s compensation. This practice may disclose your health information as necessary to comply with worker’s compensation laws or similar programs that provide benefits for work-related injuries.
6. Comply with the Law
This practice may disclose your health information where state or federal law requires it. Your health information may also be disclosed for military, national security, prisoner, and government benefits. Any health information disclosed for government benefits are limited to health plans only.
This practice may disclose your health information to law enforcement officials for the following reasons:
- To comply with a valid search warrant or court order, grand jury subpoena, or administrative subpoena that is legally enforceable;
- To report certain types of wounds or physical injuries if required to do so by law;
- To assist law enforcement officers with identifying or locating a suspect, fugitive, witness, or missing person, provided that only limited PHI is disclosed;
- You are the victim of a crime and (1) we have been unable to obtain your consent because of an emergency or your incapacity; (2) law enforcement officials represent that they need this information immediately to carry out their law enforcement duties; and (3) in this practice’s professional judgment, disclosures to these officers is in your best interest;
- In the event of your death, if this practice suspects that your health resulted from criminal conduct; or
- If a patient commits a crime on the premises or against our personnel, this practice is allowed to report certain information to law enforcement that is directly related to the crime or threatened crime and that is limited to the circumstances of the incident and patient status, name, address and last known whereabouts regarding the individual committing or threatening to commit the crime.
7. Change of Ownership
In the event that this practice is sold or merged with another practice or organization, your health information and record will become the property of the new owner.
III. Changes to the Terms of this Notice of Privacy Practices
This practice may change the terms of this Notice of Privacy Practices at any time. All changes made will apply to all of the information that this practice has about you. A new Notice of Privacy Practices will be available upon request, and in our office.
IV. File a Report
If you believe that your rights have been violated, you may file a complaint with this practice.
You also have the right to submit a formal complaint to the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to:
Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
You may also call 1-877-696-6775 or visit www.hhs.gov/ocr/privacy/hipaa/complaints/.
This practice will not retaliate against you for filing a complaint.