Upper Perk Physical Therapy & Sports Rehab Inc., New Hope Physical Therapy & Sports Rehab, Springfield Physical Therapy & Sports Rehab
NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

UPPT, NHPT, & SPT is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices concerning your health information. This notice takes effect 10/01/03 and will remain in effect until we replace it.

A. USES AND DISCLOSURES OF HEALTH INFORMATION: UPPT, NHPT, & SPT collects health information from you and is maintained in your chart and on the computer. We are permitted by law to use or disclose your health information for treatment, payment and healthcare operations. For example:
1. Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
2. Payment: We may use and disclose your health information to obtain payment for services we provide to you.
3. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
4. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use of disclose your health information for any reason except those described in this Notice.
5. Notification and Communication with family: We may disclose your health information 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 able and available to agree or object, we will give you the opportunity to object prior to making this notification. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.
6. Required by law: As required by law, we may use and disclose your health information.
7. Public health: As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.
8. Health Oversight Activities: We may disclose your health information to health agencies during the course of audits, investigations, inspections, licensure and other proceedings.
9. Judicial and Administrative Proceedings: We may disclose your health information in the course of any administrative or judicial proceeding.
10. Law Enforcement: We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena and other law enforcement purposes.
11. Deceased person information: We may disclose your health information to coroners, medical examiners and funeral directors.
12. National Security: We may disclose your health information for military, national security or similar government functions.
13. Worker's Compensation: We may disclose your health information as necessary to comply with worker's compensation laws.
14. Marketing: We may contact you to provide appointment reminders or to give you information about other treatments or health-related benefits and services that may be of interest to you.
15. Change of Ownership: In the event that UPPT, NHPT, & SPT is sold or merged with another organization, your health information/record will become the property of the new owner.

B. PATIENT RIGHTS:
1. Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you a reasonable fee according to the laws and regulations of the State of Pennsylvania for staff time to locate and copy your health information, and postage of you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)
2. Disclosure Accounting: You have the right to request that we place additional restrictions on our use of disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
3. Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
4. Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.
5. You have a right to a paper copy of this Notice.

C. CHANGES TO THIS NOTICE OF PRIVACY PRACTICES:
UPPT, NHPT, & SPT reserves the right to amend this Notice of Privacy Practices at any time in the future, and to make the new provisions effective for all information that it maintains, including information that was created or received prior to the date of such amendment. Until such amendment is made, UPPT, NHPT, & SPT is required by law to comply with this Notice. Revised Notices will be posted in a prominent location at each UPPT, NHPT, & SPT office, and available upon request by contacting the Office's Privacy Official.

D. COMPLAINTS:
Complaints about this Notice of Privacy Practices or how UPPT, NHPT, & SPT handles your health information should be directed to the appropriate UPPT, NHPT, & SPT Office Privacy Official at:

Jay Kauffman
Upper Perk Physical Therapy & Sports Rehab, Inc.
2767 Geryville Pike
Pennsburg, PA 18073

I have received a copy of Notice of Privacy Practices for Upper Perk Physical Therapy & Sports Rehab, Inc, New Hope Physical Therapy & Sports Rehab and Springfield Physical Therapy & Sports Rehab.

Signature_____________________________________ Date________________