NOTICE OF

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

This information is made available to all patients

Our Mission Regarding Your Health Information

Our mission is to be a good steward of our patients’ health information. We shall strive to maintain the
privacy, security and confidentiality of all personal health information we create or possess. All of our
work procedures shall be designed and practiced to protect our patients’ personal health information. Our
goal is to be recognized by our patients, business associates, and the public as a professional
organization of caring, “privacy-minded” individuals.

Introduction

This Notice is provided to you in accordance with the Privacy Regulations of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). The Privacy regulations issued by the Department of
Health and Human Services require us to inform you of our privacy practices as they relate to your health
information.

We understand that your medical information is personal to you, and we are committed to protecting this
information about you. We create medical records, both paper and electronic, about care we provide for
you. We need this record in order to provide for your health care needs, and to comply with professional
and legal requirements. This record of information is often referred to as your health or medical record
and under HIPAA, is referred to as Protected Health Information (PHI). Your medical record serves as a:

• Basis for planning your care and treatment

• Means of communication among the many health professionals who contribute to your care
• Legal document describing the care you received
• Means by which you or a third-party payer can verify that services billed were actually provided
• Tool in educating health professionals
• Source of data for medical research
• Source of information for public health officials charged with improving the health of this State and
Nation
• Source of data for our planning and marketing
• Tool with which we can assess and continually work to improve the care we render and the
outcomes we achieve.

Understanding what is in your record and how your health information is used helps you ensure its
accuracy, better understand how, when, and why others may access your PHI, and make more informed
decisions when authorizing disclosures to others.

Health Care Provider Responsibilities

The following section describes the obligations of Performax Physical Therapy regarding the use
and disclosure of your medical information.

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The law requires us to:

• Make sure that your health information is kept private

• Provide you with this notice explaining our legal duties and privacy practices with respect to
information we collect and maintain about you
• Accommodate reasonable requests you may have to communicate health information by
alternative means or in alternative locations
• Notify you if we are unable to agree to your requested restriction
• Follow the conditions of the Notice that is currently in effect

How we may use and disclose medical information about you:

The following categories that are bulleted are italicized describe different ways that we use, share, and
disclose your PHI with others. Each category of uses or disclosures provides a general explanation and
provides some examples of uses. Not every use or disclosure in a category is either listed or actually in
place. The explanation is provided for your general information only.

We will use your health information for treatment.

For example: We use medical information about you to provide you with current or prospective physical
therapy treatment of services. Information provided by you, your referring physician, physical therapist, or
other member of your health care team may be documented in your record and used to determine the
course of treatment that should work best for you. It is usual for us to ask you about how your affected
body area is feeling. We will especially ask you questions about your pain level, tolerance to treatment,
and how your current function affects your daily activities. Your physical therapist may communicate with
your physician either verbally or in writing. We normally provide your physician with a written evaluation of
our initial findings and a summary of your progress in physical therapy. We may also provide a
subsequent health care provider with copies of various reports.

We will use your health information for regular health operations.

We use and disclose medical information about you so that we can operate our practice. We use and
disclose medical information about you so that we can run our practice more efficiently and make sure
that all of our patients receive quality care. These uses may include reviewing our treatment and services
to evaluate the performance of our staff, deciding what additional services to offer and where, deciding
what services are not needed, and whether new treatments are effective.

Treatment Setting: Physical exercise plays a prominent role in your care at our facility. The gym area of
our facility is a common treatment area used to instruct patients in, and observe, their performance of
prescribed exercises. In this setting it is probable that other patients may learn of your physical ailment.
For Example: You may be performing an exercise similar to that of another patient. It would be easy for
you to infer that they are being treated for a similar malady. Additionally, others may overhear a
conversation between you and your therapist.

Business Associates: There are some services provided to you, our patient, through contacts with
business associates. Examples include outside vendors who provide rental units, on-call or fill-in therapist
services, and other services we may use when providing you access to your medical record. When these
services are contracted, we may disclose your health information to our business associate so that they
can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered.
However, we do require that our business associates act appropriately to protect your health
information

Directory: Because of the size and scope of our practice, a hospital-like directory of your status and
location is not used. However, unless you object, we may use or disclose information about your
presence in our facilities to those who ask for you by name. For example: If a person telephones, or
personally asks to speak to you while you are at our office, or asks if you have arrived or left from your
appointment, we will disclose that information to the person who has inquired about you by name.
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Payment: We may use and disclose medical information about you for services and procedures so that
they may be billed and collected from you, an insurance company, or other third party. For Example: We
often need to give your health care information about treatment you received at our practice to obtain
payment or reimbursement for care. We may also tell your health plan and/or referring physician about a
treatment you are going to receive to obtain prior approval or to determine whether your plan will cover
the treatment.

Appointment and patient recall reminders: We may use and disclose medical information about you as a
reminder that you have an appointment with our practice. This contact may be by phone, in writing,
e-mail or otherwise, and may involve leaving such message where it could potentially be “picked up” by
others.

Mailing lists and direct mailings: We maintain a database of our patients’ mailing addresses. We protect
this database and do not engage in the practice of selling or otherwise distributing our mailing list or your
demographic data to others. We use this list to include you in our regular mailings, such as birthday
cards, newsletters, and to keep you informed of new services we may offer in the future.

Communication with family and friends: Health 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.

Research: Our practice does not routinely participate in formal research projects. However, under certain
circumstances we may use and disclose medical information about you for research purposes regarding
efficiency or treatment protocols and the like. We will, as required by law, obtain your specific
authorization to release information to a qualified researcher.

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
statute.

Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the
institution or agents thereof health information necessary for your health and the health safety of other
individuals.

Law Enforcement: We may disclose health information for law enforcement purposes as required by
federal, state, or local law.

Lawsuits and disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information
about you in response to a court or administrative order. This is particularly true if you make your health
an issue. We may also disclose medical information about you in response to a subpoena, discovery
request, or other lawful process by someone else involved in the dispute. We may also use such
information to defend ourselves, or any member of our practice, in any actual or threatened action.

We will notify you if we discover a breach of your PHI

A breach is defined as an impermissible use or disclosure under the Privacy Rule that compromises the
security or privacy of your PHI and that poses a significant risk of financial, reputational, or other harm to
you. If we discover a breach of your PHI, we will notify you in writing describing the nature of the breach,
the type of patient information disclosed, steps you can take to protect yourself, and steps our practice is
taking to remedy the situation

Patient Rights

The following section describes your rights regarding the use and disclosure of your medical
information.

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While your health records are the physical property of the healthcare provider who created it, you have
the following rights regarding medical information we maintain about you:

Right to inspect and copy.

You have the right to inspect and obtain a copy of medical information that may be used to make
decisions about your care. This includes your own medical and billing records. Upon proof of an
appropriate legal relationship, records of others related to you or under your care (guardian or custodial)
may also be disclosed.

To inspect and obtain a copy of your medical record, you must first submit your request in writing to our
Privacy Officer. Ask the receptionist or office manager for the name of the Privacy Officer. If you request a
copy of the information, we may charge you a reasonable, cost-based fee for the costs of copying,
mailing, or other supplies associated with your request.

Right to request an amendment to your health record as provided in 45 CFR Part 164.526.

You may ask us to amend information in your medical record if you feel that the information we have
about you in your record is incorrect or incomplete. You have the right to request an amendment for as
long as the practice maintains your medical record following the procedure below.

To request an amendment, your request must be submitted in writing, along with your intended
amendment and a reason that supports your request to amend. The amendment must be dated and
signed by you and notarized. We may deny your request if it is not in writing or does not include a reason
to support the request.

If we grant the request, we will make the correction and distribute the correction to those who need it and
those you identify to us that you want to receive the corrected information. If we deny your request for
amendment/correction, we will notify you why, how you can attach a statement of disagreement to your
record (which we may rebut), and how you can complain. We do not have to grant your request if you ask
us to amend information that:

• Was not created by us. If, as in the case of a consultation report, or X-Ray report from another
provider, we did not create the record, we cannot know whether it is accurate. In these cases, you
would need to seek an amendment/correction from the party who created the record
• Is not part of the medical information kept by or for the practice as described immediately above
• Is complete and accurate

Right to an accounting of disclosures.

You have the right to request an “accounting of disclosures”. This is a list of the disclosures of your
medical information to others for purposes other than treatment, payment, or healthcare operations.

To request this list, you must submit your request in writing. Your request must state a time period not
longer than 6 (six) years back and may not include dates before April 14, 2003 (or the actual
implementation date of the HIPAA Privacy Regulations). Your request should indicate in what form you
want the list. We must provide this accounting within 60 days. Our accounting must include:

• The date of each disclosure

• The name and address of the organization or person who received the PHI
• A brief description of the information disclosed
• A brief statement of the purpose of the disclosure that reasonably informs you of the basis for the
disclosure or, in lieu of such statement, a copy of your written authorization, or a copy of the
written request for disclosure

You may receive from us one free accounting in any 12-month period. We reserve the right to charge a
reasonable, cost-based fee for more frequent requests.
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Right to request restrictions.

You have the right to request a restriction or limitation on the medical information we use or disclose
about treatment, payment or healthcare 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 (family member or friend).

To request restrictions, you must make your request in writing. Your request must indicate:

• What information you want to limit

• Whether you want to limit our use, disclosure, or both
• To whom you want the limits to apply, (e.g., disclosures to your children, parents, spouse, etc.)

If we agree with your request for restriction, we will comply. However, we are not required to comply with
every request.

Right to request confidential communications.

You have the right to request that we communicate with you about medical matters in a certain way or at
a certain location (e.g., you can ask that we only contact you at work or by mail, that we not leave voice
mail, etc.)

To request confidential communications, you must make your request in writing. We will not ask you for
the reason for your request. We will attempt to accommodate all reasonable requests.

Right to a copy of this notice

You have a right to a copy of this Notice at any time.

Complaints

If you believe your privacy rights have been violated, you may file a written complaint with the practice. To
file a complaint, contact our office manager, who will direct you on how to file a formal complaint. Our
office manager can be reached at 303-932-2500. If we are unable to satisfy your complaint, you may file
a complaint with the Office of Civil Rights, US Department of Health and Human Services. All complaints
must be submitted in writing, and all complaints will be investigated, without repercussion to you. The
address for the OCR is listed below:

Office of Civil Rights

US Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509R, HHH Building
Washington, D.C. 20201

You will not be penalized for filing a complaint.

We will make every effort to mitigate your concerns about our privacy practices. We will not penalize you
in any way for filing a complaint against us. Further, you have protections under HIPAA that prohibit us
from retaliating against any complaint you may make against us.

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 Changes to this Notice

We reserve the right to change this Notice at any time. 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 may receive from you in the future. We will post a copy of the current notice in our offices. The notice
will contain the date of the last revision and the effective date. In addition, each time you visit our practice
for treatment or health care services, you may request a copy of the current notice in effect.

Notice Version 1.02

Effective Date April 30, 2010

Performax Physical Therapy, Inc.

5920 S. Estes St., Suite 100
Littleton, CO 80123
303-932-2500

Performax Front Range Physical Therapy, LLC

8200 E. Belleview Ave., Suite 505E
Greenwood Village, CO 80111
303-741-0235

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