Effective April 14, 2003

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.

This page describes the type of information we gather about you, with whom that information may be shared and the safeguards we have in place to protect it. You have the right to the confidentiality of your health information and the right to approve or refuse the release of specific information except when the release is required by law. If the practices described in this brochure meet your expectations, there is nothing you need to do. If you prefer that we not share information, we may honor your written request in certain circumstances described below. If you have any questions about this notice, please contact our Privacy Officer at the address below.

WHO WILL FOLLOW THIS NOTICE

This notice describes SOMA Physical Therapy’s practices regarding the use of your protected health information and that of:

• Any health care professional authorized to enter information into your medical record.
• All employees, staff and other personnel who may need access to your information.

OUR PLEDGE REGARDING PROTECTED HEALTH INFORMATION

We understand that information about you and your health is personal. Protecting health information about you is important. We create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by SOMA Physical Therapy, whether made by health care professionals or other staff.

This notice will tell you about the ways in which we may use and disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of protected health information.

We are required by law to:

• keep health information that identifies you private
• give you this notice of our legal duties and privacy practices with respect to health information about you
• follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that we may use and disclose protected health information.

For Treatment. We may use health information about you to provide you with physical therapy, treatment, or services. We may disclose health information about you within the clinic to physical therapists, massage therapists, Pilates instructors, athletic trainers, and administrative staff. We also may disclose health information about you to people outside the clinic who may be involved in your care such as physicians, nurses, physician assistants, and chiropractors.

For Payment. We may use and disclose health information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. We may also use and disclose health information about you to obtain prior approval or to determine whether your insurance will cover the treatment.

For Health Care Purposes. We may use and disclose information about you for health care purposes. This is necessary to make sure that all of our patients receive quality care. For example, we may use protected health information to review our treatment and services and to evaluate the performance of our staff in caring for you.

Business Associates. There are some services provided by us through contracts with business associates. Examples include massage therapy, Pilates, athletic training, and payment reconciliation/collection services. When these services are contracted for, we may disclose health information about you to our business associate so that they can perform the job we have asked them to do or to bill you or your third-party payor for services rendered. To protect health information about you, we require our business associates to appropriately safeguard the information.

Appointment Reminders. We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care.

Treatment Alternatives. We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. We may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care.

As Required By Law. We will disclose health information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

SPECIAL SITUATIONS

Workers’ Compensation. We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release health information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons or similar process
• To identify or locate a suspect, fugitive, material witness, or missing person
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement
• In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

You have the following rights regarding protected health information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy health information that may be used to make decisions about your care. This includes medical and billing records produced within our clinic.

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to our Privacy Officer at the address on the last page. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

Right to Amend. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept.

To request an amendment, your request must be made in writing and submitted to our Privacy Officer. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment
• Is not part of the medical information kept by or for our office
• Is not part of the information which you would be permitted to inspect and copy
• or, Is accurate and complete.

Right of Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we made of medical information about you.

To request an accounting of disclosures, you must submit your request in writing to our Privacy Officer. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to our Privacy Officer at the address below. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.

Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to our Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice, please request one in writing from our Privacy Officer at the address below.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice which will contain the effective date.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with SOMA Physical Therapy or with the Secretary of the Department of Health and Human Services. To file a complaint with SOMA Physical Therapy, contact our Privacy Officer at the address and phone number listed below. All complaints must be submitted in writing.

You will not be penalized for filing a complaint.

OTHER USES OF PROTECTED HEALTH INFORMATION

Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, thereafter we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

PRIVACY OFFICER

Wendy Diamond
2400 Spruce, Suite 101
Boulder, Colorado 80302
P 303-440-3359
F 303-545-9527
Wendy@somapt.com