Steppin' Up Physical Therapy
Summary of HIPAA NOTICE OF PRIVACY PRACTICES
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.

Updated 2014

A full version (7 page) of this Privacy Notice is available to you at the front desk of our locations. Under the Health Insurance Portability and Accountability Act of 1996 (" HIPAA") we are required to maintain the privacy of your protected health information and provide you with notice of our legal duties and privacy practices with respect to such protected health information.

We are required to abide by the terms of the notice currently in effect. We reserve the right to change the terms of our notice at any time and to make the new notice provisions effective for all protected health information that we maintain. In the event that we make a material revision to the terms of our notice, a revised notice will be made available to you within 60-days of such revision. If you should have any questions or require further information, please contact our external Privacy Officer at (260) 497-7191.

How We May Use or Disclose Your Health Information
The following describes the purposes for which we are permitted or required by law to use or disclose your health information without your consent or authorization. Any other uses or disclosures will be made only with your written authorization and you may revoke such authorization in writing at any time.

• Treatment: We may use or disclose your health information to provide you with medical treatment, services or coordinate your care with another health care provider. For example, information obtained by a provider providing health care services to you will record such information in your record and that record may be shared with other providers involved in your care.
• Payment: We may use or disclose your health information in order for services you receive at our office to be paid by your insurance carrier. For example, we may disclose appropriate information for reimbursement, collection or payment purposes.
• Health Care Operations: We may use or disclose your health information for health care operations. Health care operations include, but are not limited to, quality assessment and improvement activities, underwriting, premium rating, management and general administrative activities. For example, members of our quality improvement team may use information in your health record to assess the quality of care that you receive and determine how to continually improve the quality and effectiveness of the services we provide.
• Business Associates: There may be instances where services are provided to our office through contracts with third party "business associates". Whenever a business associate arrangement involves the use or disclosure of your health information, we will have a written contract that requires the business associate to maintain the same high standards of safeguarding your privacy that we require of our own staff members and affiliates.
• Required by Law: We will disclose medical information about you when required to do so by federal, state or local law.
• Communications: Our professionals, using their best judgment, may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or payment related to your care. The office may also disclose your condition to family or friends who accompany you to our offices. We may call you at a phone number provided by you and leave a message either with the person answering the phone or on an answer machine. The message will be limited to the minimum information necessary to inform you of the call or need for a return call. We may also send you communications through the mail.
• Coroners, Medical Examiners and Funeral Directors: We may disclose health information to a coroner or medical examiner. We may also disclose medical information to funeral directors consistent with applicable law to carry out their duties.
• Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.
• Workers' Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers' compensation or other similar programs established by law.
• To Avert a Serious Threat to Health or Safety: Consistent with applicable federal and state laws, we may use and disclose health information when necessary, to prevent a serious threat to your health and safety or the health and safety of the public or another person.
• Military and Veterans: If you are a member of the armed forces, we may disclose health information about you as required by military command.
• Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law, including audits, investigations, inspections, and licensure.
• Protective Services for the President, National Security and Intelligence Activities: We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations, or for intelligence, counterintelligence, and other national security activities authorized by law.
• Law Enforcement: We may disclose health information when requested by a law enforcement official as part of law enforcement activities; investigations of criminal conduct; in response to court orders; in emergency circumstances; or when required to do so by law.
• Inmates: We may disclose health information about an inmate of a correctional institution or under the custody of a law enforcement official to the correctional institution or law enforcement official.
• Marketing/Fundraising: Marketing done internally for the sole purpose of informing our patients of our services products may be done without authorization. For example, informing you of a product or service that we offer that we think may benefit you. An example of marketing that would require your authorization would be marketing a product or service for someone (pharmaceutical company) other than our practice. You have the option of not participating in any fundraising that we may conduct, to do so, please notify our Privacy Officer of your choice not to participate.
• Sale of PHI: We must obtain your authorization prior to selling your health information with a few exceptions such as for the sale, transfer, merger, or consolidation of all or part of Organization. Other exceptions are disclosures permitted by HIPAA.

Your Rights Regarding Your Health Information
The following describes your rights regarding the health information we maintain about you. To exercise your rights, you must submit your request in writing, using the designated form, submitted in a sealed envelope made to the attention of the Privacy Officer, Gloria May, 10006 Auburn Park Dr., Fort Wayne, IN 46825

• Right to Request Restrictions: You have the right to request a restriction or limitation on the medical 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 medical 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. For example, you could ask that we not use or disclose information about a surgery you had. You also have the right to restrict disclosure of any health information on a service you paid for out-of-pocket.
• Right to Receive Confidential Communications: You have the right to request that we send communications that contain your health information by alternative means or to alternative locations. We must accommodate your request if it is reasonable.
• Right to Inspect and Copy: You have the right to an inspection, by appointment only, and to a copy of health information that we maintain about you. If copies are requested or you agree to a summary or explanation of such information, we may charge a reasonable, cost-based fee for the costs of copying, including labor and supply cost of copying; postage; and preparation cost of an explanation or summary, if such is requested. The cost may be in accordance with Indiana State Law, which is, as of December 1, 2005, $1per page for pages 1-10 and $.50 per pages eleven (11) through fifty (50) and $.25 per page from fifty-one (51) and higher. We may deny your request to inspect and copy in certain circumstances as defined by law. If you are denied access to your health information, you may request that the denial be reviewed.
• Right to Amend: You have the right to have us amend your health information for as long as we maintain such information. Your written request must include the reason or reasons that support your request. We may deny your request for an amendment if we determine that the record that is the subject of the request was not created by us, is not available for inspection as specified by law, or is accurate and complete.
• Right to Receive an Accounting of Disclosures: You have the right to receive an accounting of disclosures of your health information made by us in the six years prior to the date the accounting is requested (or shorter period as requested). This does not include disclosures made to carry out treatment, payment and health care operations; disclosures made to you; communications with family and friends whom you have authorized; for national security or intelligence purposes; to correctional institutions or law enforcement officials; or disclosures made prior to the HIPAA compliance date of April 14, 2003. Your first request for accounting in any 12-month period shall be provided without charge. A reasonable, cost-based fee shall be imposed for each subsequent request for accounting within the same 12-month period.
• Right to a Breach Notification: You have the right to be notified of a breach of your health information that may pose a risk to you financially, your reputation, or otherwise. The notification will be in writing informing you of what occurred and how we may help you monitor this breach. Further reporting to the Department of Health and Human Services and/or the state Attorney General may also be required.
• Right to Obtain a Paper Copy: You have the right to obtain a paper copy of this Notice of Privacy Practices at any time.

How to File a Complaint if You Believe Your Privacy Rights Have Been Violated
If you believe that your privacy rights have been violated, please submit your complaint in writing to:

Steppin' Up Physical Therapy
Attn: Gloria May
10006 Auburn Park Drive
Fort Wayne, IN 46825

You may also file a complaint with the Secretary of the Department of Health and Human Services or Office of Civil Rights. You will not be retaliated against for filing a complaint.