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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED, AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY
Your medical information (“PHI”) is the information collected by your physical therapists or other caregivers during the time you are being treated at the clinic. It is private, and nobody without a legitimate need to know can access it. The law requires the Alliance Physical Therapy Partners’ Provider (“Provider”) to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices (this “Notice”). In the unlikely event your medical information is not secure, the Provider will furnish you with immediate notification. The Provider will not use or disclose your health information except as described in this Notice unless you tell us we can do so in writing. This Notice applies to all medical records generated during your participation in programs and services of Agile Virtual Care.
TO WHOM THIS NOTICE APPLIES
This Notice is a joint notice for all Alliance Physical Therapy Partners affiliated entities, each of which follows the terms of this Notice and is referred to in this Notice as “we,” “us” or “our”. A complete listing of all the Alliance Physical Therapy Partners affiliated entities and their respective locations covered by this Notice is available online at www.alliancePTP.com, at the clinic or facility where you are receiving care or by calling (616) 356-5000. The list may change; however, a change to the list does not constitute a material change in the practices described in this Notice. In addition, this Notice applies to all our employees, management, contractors, student interns, and volunteers.
EFFECTIVE DATE OF NOTICE
This Notice is effective as of October 12, 2020. We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the PHI we maintain within the scope of federal and state privacy laws. If our information practices change, we will amend our Notice. Any changes we make in our privacy practices will affect all PHI information we maintain. You are entitled to receive a revised copy of the Notice. You may by calling our Corporate Office at (616) 356-5000 or email us at firstname.lastname@example.org and request a copy. It will also be made available at each of our service locations and on the website.
HOW WE MAY USE YOUR HEALTH INFORMATION
The following categories describe the ways in which the Provider may use and disclose your health information:
Treatment: The Provider may use your health information in the provision and coordination of your healthcare. We may disclose all or any portion of your medical record information to your physician, consulting physician(s), nurses and other healthcare providers who have a legitimate need for such information in the care and continued treatment of the patient.
Payment: We may need to share a limited amount of your PHI to obtain payment for the services we provided to you. Examples include:
• To Determine Eligibility – We may contact the company or government program paying for your healthcare to determine your eligibility for benefits, co-payments, coinsurance or deductible.
• For Claims Submission – We will submit a claim to obtain payment for services we provided to you. The claim form must contain certain information to identify you, your medical diagnosis and the treatment we provided to you.
Healthcare Operations: We may use and disclose your PHI to conduct our healthcare operations and to improve our quality of care. Healthcare operations include, but are not limited to, activities such as case management and care coordination, outcome evaluation, and training programs – including those in which students, trainees or healthcare practitioners learn under supervision.
Appointment Reminders: We may use and disclose medical information to remind you of an appointment you scheduled for treatment with us.
Business Associates: We contract certain services with business associates, such as document destruction and document storage companies. Business associates are required by federal law to protect your PHI.
For Marketing Purposes: We may use your PHI to communicate about a product covered by your health plan or about treatment alternatives related to your care coordination or about health-related services or benefits that may interest you. We may also use your PHI for streamlined marketing communications, including, but not limited to, home exercise programs. Authorization is not required for face-to-face communication.
Person Involved in Your Care: We may disclose your PHI to persons involved in your care, such as friends or family members. We may also give information to someone who pays for your care. You have the right to approve such releases, unless you are unable to function, or if there is an emergency.
Required By Law: We may use and disclose your PHI when that use or disclosure is required by law.
Public Health Activities: We may disclose PHI as required by law to public health or legal authorities charged with preventing or con-trolling disease, injury or disability.
To Conduct Health Oversight Activities: We may be required to disclose your PHI to appropriate health oversight agencies so they can monitor, investigate, inspect, discipline or license those who work in the healthcare system, or for government benefit programs
Workers’ Compensation: The Provider may release medical information about you for workers’ compensation or similar programs that provide benefits for work-related injuries or illnesses.
Judicial and Administrative Proceedings: As permitted or required by law, we may disclose your PHI in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.
Report Abuse, Neglect or Domestic Violence: We may disclose your PHI to public authorities as required by law to report abuse or neglect.
For Law Enforcement Purposes: As permitted or required by law, we may disclose your PHI to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.
Inmates: If you are an inmate of a correctional institution, we may disclose your PHI to the institution or its agents for your health and the health and safety of other individuals.
Serious Threat to Health or Safety: Consistent with applicable law and ethical standards of conduct, we may disclose your PHI if we, in good faith, believe such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.
For Research Purposes: We may use or release your PHI for re-search purposes. All research projects require special permission before they begin. This process may include asking you for authorization; however, in certain circumstances, your PHI may be used or released without your authorization.
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.
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Acknowledgment of receipt of Notice of Privacy Practices: We will request you to sign a separate form acknowledging you were offered or received a copy of this Notice. If you elect not to sign the acknowledgment, one of our staff members will sign on your behalf attesting the Notice was provided to you. A copy of the acknowledgment will be maintained in your patient record.
YOUR RIGHTS REGARDING YOUR PHI
Your Rights: You have the following rights regarding your PHI. You have the right to:
Confidential Communications: You have the right to receive confidential communications regarding your medical information. For example, you may request that the Provider contact you only at work or by mail. We will honor all reasonable requests.
Video Monitoring: Agile Virtual Care utilizes HIPAA compliant video cameras in the open gym area of this facility so as to ensure the safety of our patients at all times. Video recordings are never distributed, sold, or played on the internet, social media, or YouTube for general viewing. Videos will not be part of the medical record.
Right to Inspect, Copy, and Amend: You have the right to inspect and copy your medical information. We may deny your request to inspect or copy your medical information under very limited circumstances. You have the right to amend your medical information. Any request for amendment should be submitted to the Provider in writing, stating a reason in support of the amendment. We may deny your request to amend your medical information.
Right to an Accounting: You have the right to obtain an accounting of the disclosures of your medical information made during the preceding six (6) year period.
Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your medical information. The Provider is not required to honor your request except where: (i) the disclosure is for the purpose of carrying out payment or health-care operations and is not otherwise required by law, and (ii) the medical information pertains solely to a healthcare item or service for which you, or person other than the health plan on your behalf, has paid the Provider in full. If you pay for the service or item out-of-pocket in full, you have the right to request that Provider not share your PHI with your health insurer.
Right to Receive a Paper Copy: You have the right to receive a paper copy of this Notice.
Right to Receive Electronic Copies: You have the right to receive electronic copies of your medical information.
Right to Revoke Authorization: You have the right to revoke your authorization to use or disclose your medical information, except to the extent that action has already been taken in reliance on your authorization. A request to exercise any of these rights must be submitted, in writing, to Agile Virtual Care, LLC c/o Alliance Physical Therapy Partners – Privacy Officer, 607 Dewey Ave NW, Suite 300, Grand Rapids, MI 49504.
Where applicable, this Provider complies with the California Consumer Protection Act. In addition to the rights stated within this notice, California residents have the right to:
FOR MORE INFORMATION OR TO REPORT A PROBLEM
If you have questions about this Notice, please contact our Privacy Officer at
607 Dewey Avenue, Ste 300, Grand Rapids, MI 49504
or (866) 647-6414 or e-mail email@example.com.
If you believe your privacy rights have been violated, you may file a complaint with the Office of Civil Rights, US Department of Health and Human Services, by sending a letter to: 200 Independence Ave. S.W., Washington, D.C. 20201, call 1.877.696.6775 or visit www.hhs.gov/ocr/privacy/hipaa/complaint. You may also file a complaint with us by contacting our front desk.
All complaints must be submitted in writing. There will be no retaliation for filing a complaint.
CHANGES TO THIS NOTICE
The Provider will abide by the terms of the Notice currently in effect. The Provider reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all PHI it maintains. An updated version of the Notice may be obtained at the clinic and Agile Virtual Care’s website at https://www.agilevirtualcare.com.
NOTICE EFFECTIVE DATE
This Notice is effective October 12, 2020.