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

    Uses and Disclosures We will use your Protected Health Information (PHI) for the purposes of treatment, payment and health care operations.

    Treatment includes the disclosure of health information to other providers who have referred you for services or are involved in your care. This may include doctors, nurses, technicians and other allied health therapists.

    Payment includes the disclosure of health information to your insurance company, so payment can be obtained for services rendered. Your insurance company may make a request to review your medical record to determine that your care was necessary.

    Health Care Operations includes the utilization of your records to monitor the quality of care being given at our facility or for business planning activities.

    Other Special Uses Our practice may use your PHI to send you an appointment reminder or inform you of our other health-related products and services.

    Uses and Disclosures Required by Law The federal health information privacy regulations either permit or require us to use or disclose your PHI in the following ways: we may share some of your PHI with a family member or friend involved in your care if you do not object we may use your PHI in an emergency situation when you may not be able to express yourself, and we may use or disclose your PHI for research purposes if we are provided with very specific assurances that your privacy will be protected. We may also disclose your PHI when we are required to do so by law, for example by court order or subpoena. Disclosures to health oversight agencies are sometimes required by law to report certain diseases or adverse drug reactions.

    We may use and disclose health information about you to avert a serious threat to your health or safety or the health/safety of the public or others. If you are in the Armed Forces, we may release health information about you when it is determined to be necessary by the appropriate military command authorities. We may also release information about you for workers' compensation or other similar programs that provide benefits for work-related injury or illness. Your authorization is required before your PHI may be disclosed by us for other purposes.

    Restrictions

    You have the right to request restrictions on how your PHI is used, however we are not required to agree with your request. If we do agree, we must abide by your request.

    Confidential Communications

    You have the right to request confidential communication from us at a location of your choosing. This request must be in writing.

    Access to PHI

    You have the right to request an amendment be made to your PHI, if you disagree with what it says about you. The request must be made in writing. If we disagree with you, we are not required to make the change. You do have the right to submit a written statement about why you disagree that will become part of your record. We may not amend parts of your medical record that we did not create.

    Accounting of Disclosures

    After April 4, 2003 you have the right to request an accounting of the disclosures made in the previous six years. These will not include those made for treatment, payment or health care operations or for which we have obtained authorization.

    Complaints

    If you feel that your privacy rights have been violated, you have the right to make a complaint in writing to us without fear of retaliation. Your complaint should contain enough specific information so that we may adequately investigate and respond to your concerns. If you are not satisfied with our response, you may complain directly to the Secretary of Health and Human Services.

    Our Duty to Protect Your Privacy

    We are required to comply with the federal health information privacy regulations by maintaining the privacy of your PHI. These rules require us to provide you with this document, our Notice of Privacy Practices. We reserve the right to update this notice if required by law. If we do update this notice at any time in the future, you will receive a revised notice when you seek treatment from us.

    Privacy Contact

    If you would like more information about our privacy practices or to file a complaint you may contact
    Name: Michele Forsberg PT
    Title: Privacy Officer
    Address: 2919 17th Ave, Suite 105, Longmont, CO 80503
    Phone: 720-204-6546

    Effective Date: This notice will take effect on December 13, 2018

    Cacellation Policy: It is our intention at Align PT to provide all of our clients with the best possible service. In fairness to all of our clients as well as our therapists we ask that you contact us within 24 hours of a cancellation so that we may accommodate our other clients’ needs for appointments. We charge a fee equal to the cost of your session, which you will incur for less than 24 hours’ notice, sudden illness excepted. We thank you for your understanding and consideration of Align PT staff as well as fellow clients.

    Payment at time of service: Payment is expected at the time of service, we do not bill insurance directly but are happy to provide you with an itemized receipt which you can submit to your insurance company for reimbursement. We accept check, cash, MC/VISA/Discover/American Express. You will be charged $35 per returned check.

    Durable Goods and Supplies: that are required for your rehabilitation, including tape and therabands are responsibility of the client.

  • Consent for Treatment

  • I hereby request and consent to evaluation and treatment at Align PT to be performed by a physical therapist. I understand that results of treatment cannot be guaranteed.

  • HIPPA Compliance

  • I hereby give consent to Align PT to use and disclose Protected Health Information (PHI) about me to carry out Treatment, Payment, and Health Care Operations (TPO).

    I have read and understand the Align PT Notice of Privacy Practices. I understand that Align PT may use or disclose my personal health information for the purposes of providing treatment, obtaining payment, internal assessment of quality of care provided, as well as for administrative purposes related to treatment or payment. Align PT reserves the right to change the terms of our Notice of Privacy Practices at any time. A revised copy may be obtained upon request.

    You have a right to request us to restrict how we use and disclose your PHI for the purposes of TPO. We are not required to grant your request but if we do the restriction will be binding on us.

    You may revoke this consent in writing at any time except to the extent that the practice has already made disclosures in reliance upon you prior consent. If you choose not to sigh this consent or later revoke it, Align PT may decline to provide treatment to you.

  • If you are signing as a patient representative