Privacy Practices



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 Document Carefully.

1. About Protected Health Information (PHI).

In this Notice, “we”, “our” or “us” means that Ojai Valley Physical Therapy, Body Garage Inc. and our workforce of employees, contractors and volunteers. “You” and “your” refers to each of our patients who are entitled to a copy of this Notice.

We are required by federal and state law to protect the privacy of your health information. For example, federal health information privacy regulations require us to protect information about you in the manner that we describe here in this Notice. Certain types of health information may specifically identity you. Because we must protect this health information we call this Protected Health Information---or “PHI”. In this Notice, we tell you about:

· How we use your PHI

· When we may disclose your PHI to others

· Your privacy rights and how to use them

· Our privacy duties

· Who to contact for more information or a complaint

2. Some of the ways we use (within the organization) or disclose (outside of the organization) your Protected Health Information

We will use your PHI to treat you. We will use your PHI and disclose it to get paid for your care and related services. We use or disclose your PHI for certain activities that we call “health care operations”. We will also use or disclose your PHI as required or permitted by law. We will give you examples of each of these to help explain them but space does not permit a complete list of all uses or disclosures. This is one reason why you can contact us and ask us questions.

· Treatment

We use and disclose your PHI in the course of your treatment. For instance, once we have completed your evaluation or re-evaluation we send a copy or summary of our report to your referring physician. We also maintain records detailing the care and services you receive at our facility so that we can be accurate and consistent in carrying out that care in an optimal manner; that record also assists us in meeting certain legal requirements. These records maybe used and/or disclosed by members of our workforce to assure that proper and optical care is rendered.

· Payment

After we treat you we will, typically, bill a third party for services you received. We will collect the treatment information and enter the data into our computer and then process a claim either on paper or electronically. The claim form will detail your health problem, what treatments you received and it will include other information such as your social security number, your insurance policy number and other identifying pieces of information. The third party payor may also ask to see the records of your care to make certain that the services were medically necessary. When we use and disclose your information in this way is helps us to get paid for your care and treatment.

· Health Care Operations

We also use and disclose your PHI in our health care operations. For example our therapists meet periodically to study clinical records to monitor the quality of care at our facility. Your records and PHI could be used in these quality assessments. Sometimes we participate in student internship programs and we use the PHI of real patients to test them on their skills and knowledge. Other operational used may involve business planning and compliance monitoring or even the investigation and resolution of a complaint.

· Special Uses

We also use or disclose your PHI for purposes that involve your relationship to us as a patient. We may use or disclose your PHI to:

i. Remind you of appointments

ii. Carry out follow ups on home programs that you have been taught

iii. Advise you of new or updated services or home supplies

· Uses & Disclosures Required or Permitted by Law

Many laws and regulation apply to us that affect your PHI, they may either require or permit us to use or disclose your PHI. Here is a list from the federal health information privacy regulations describing required or permitted uses and disclosures:


i. If you do not verbally object, we may share some of your PHI with a family member or a friend if he/she is involved in your care

ii. We may use your PHI in an emergency if you are not able to express yourself

iii. If we receive certain assurance that protect your privacy, we may use or disclose your PHI for research


i. When required by law; for example, when ordered by a court to turn over certain types of your PHI, we must do so

ii. For public health activities such as reporting a communicable disease or reporting an adverse reaction to the Food and Drug Administration

iii. To report neglect, abuse or domestic violence

iv. To the government regulators or its agents to determine whether we comply with applicable rules and regulations

v. In judicial or administrative proceedings such as a response to a valid subpoena

vi. When properly requested by law enforcement officials or other legal requirements such as reporting gun shot wounds

vii. To advert a health hazard or to respond to a threat to public safety such as an imminent crime against another person

viii. Deemed necessary by appropriate military command authorities if you are in the Armed Forces

ix. In connection with certain types of organ donor programs

· Stricter Requirement That We Follow

We will follow any and all State regulations should they be stricter than these federal privacy regulations

3. Your Authorization May Be Required

In the situations noted above we have the right to use and disclose your

PHI. In some situations, however, we must ask for, and you must agree to

give, a written authorization that has specific instructions and limits on our

use or disclosure of your PHI. If you change your mind, at a later date, you

may revoke your authorization.

4. Your Privacy Rights and How to Exercise Them

You have specific rights under our federally required privacy program. Each of them is summarized below:

· Your Right to Request Limited Use or Disclosure

You have the right to request that we do not use or disclose your PHI in a particular way. However, we are not required to abide by your request. If we do agree to your request we must abide by the agreement; we have the right to ask for that request to be in writing and we will exercise that right

· Your Right to Confidential Communication

You have the right to receive confidential communications from us at a location or phone number that you specify. We have the right to ask for that request to be in writing noting the other address or phone number and confirmation that it should not interfere with your method of payment; we will exercise the right to have your request in writing

· Your Right to Inspect and Copy

You have the right to inspect and copy your PHI. Should we decline we must provide you with a resource person to assist you in the review of our refusal decision. We must respond to your request within thirty (30) days, we may charge reasonable fees for copying and labor time related to copying and we may require an appointment for record inspection; we have the right to ask for your request in writing and will exercise that right.

· Your Right to Revoke Your Authorization

If you have granted us an authorization to use or disclose your PHI you may revoke at any time it in writing. Please understand that we relied on the authority of your authorization prior to the revocation and used or disclosed your PHI within its scope

· Your Right to Amend Your PHI

You have a right to request an amendment of your record. We have the right to ask for the request in writing and we will exercise that write. We may deny that request if the record is accurate and/or if the record was not created by this facility. If we accept the

amendment we must notify you and make effort to notify others who have the original record

· Your Right to Know Who Else Sees your PHI

You have the right to request an accounting of certain disclosure that we have made over the past six years; however you may not ask for disclosures that occurred prior to April 14, 2003. We do not have to account for all disclosures, including those made directly to you, those involving treatment, payment, health care operations, those to the family/friend involved with your care and those involving national security. You have the right to request the accounting annually, we have the right to ask for the request in writing and to charge for any accounting requests that occur more than once per year; we must advise you of any charge and you have the right to withdraw your request or to pay to proceed.

· Your Right to Complain

You have the right to complain if you feel your privacy rights have been violated. You may complain directly to us or to the Secretary of Health and Human Services. We will not retaliate against you if you file a complaint about us. To file a complaint with us please contact the person identified below in this Notice. Your complaint should provide a reasonable amount of specific detail to enable us to investigate your concern.

5. Some of Our Privacy Obligations and How We Perform Them

We are required to comply with the federal health information privacy

regulations. Those rules require us to protect your PHI. Those rules also require us to give you Notice of our Privacy Practices. This document is our Notice. If you did not get a paper copy of this Notice, you may request one. We will abide by the privacy practices set forth in this Notice. However, we reserve the right to change this Notice and our Privacy Practices when permitted or required by law.

If we change our Notice of Privacy Practices we will provide our revised Notice to you when you next seek treatment from us.

6. Contact Information

If you have questions about this Notice, or if you have a complaint or

concern, please contact:

Name: Anna Kotula, DPT

Address: 407 W Ojai Ave, Suite C , Ojai CA, 93023

Phone: 805.798.1408

7. Effective Date: This notice takes effect on April 14, 2003

BOM 140-Privacy Notice 4-10-18 This notice is Copyright Protected By BCMS, Inc.

Written Authorization For Use Required