PRIVACY NOTICE

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.

DURING YOUR TREATMENT AT THE CENTER FOR MUSCLE & JOINT THERAPY, INC., PHYSICAL THERAPISTS, PHYSICAL THERAPIST ASSISTANTS AND OTHER CARE GIVERS MAY GATHER INFORMATION ABOUT YOUR MEDICAL HISTORY AND YOUR CURRENT HEALTH. THIS NOTICE WILL EXPLAIN HOW SUCH INFORMATION MAY BE USED AND SHARED WITH OTHERS. IT WILL ALSO EXPLAIN YOUR PRIVACY RIGHTS REGARDING THIS KIND OF INFORMATION.

YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED FOR THE FOLLOWING PURPOSES:

• Treatment: We will use information to provide, coordinate, and manage your care and treatment. For example, physical therapists may share your medical information with another physical therapist, physical therapist assistants, chiropractor, or physician for a consultation or a referral.

• You may request that Clinic provide you with your medical information in a confidential manner. For example, you can request that we send your appointment reminder, bills, and other mailings to a different address or that we notify you of this kind of information in another way. You must make this request in writing and specify another address or means of communication. We may ask you to give us information on how you will pay your bills.

• You may ask to see a copy your medical records, unless that information is protected by law. You must make these requests in writing. If your request to look at or copy your medical records is denied, you have the right to have the denial reviewed by a health care professional. We will act upon your request within 30 days, and we may charge you a legally acceptable amount for copying costs.

• You may ask us to change information in your medical records. If your request is denied, you can write a statement of disagreement with the denial that we will keep with your medical information.

• You may ask us to provide you with information about certain disclosures of your medical information in the past. You may request an accounting of disclosures made in the past six years, but this accounting will only cover disclosures made after April 14, 2003.

• If you have received this notice of your medical information privacy rights electronically you may ask us to provide you with a paper copy.

NOTICE OF MEDICAL INFORMATION PRIVACY RIGHTS

• Payment: We will use your information to receive payment for the services we provide. For example, we will disclose information in order to submit bills or claims to insurance companies and/or Medicare or Medicaid.
• Health Care Operations: We will use your information for certain activities related to the functioning of the Clinic. For example, we may use or disclose information for quality assurance activities, legal services, underwriting, and other business management and administrative activities.
• Appointment Reminders and Other Health Information: We may use your medical information to send you a reminder about future appointments. Your medical information may also be used to provide you with information about new or alternative treatments or other health care services.

Clinic may also use or disclose your information for the following purposes:

• To people who will be taking care of you or helping to pay for your medical bills, such as family members or close friends. Clinic will only disclose medical information that these people need to know. We may also use your medical information to let family members or other responsible people know where you are and what your general medical condition is. If you are able to make your own health care decisions, Clinic will disclose relevant medical information to family members or other responsible people if we feel it is in your best interest to do so. For example, we may provide limited medical information to allow a family member to pick up an x-ray for you.

• Under emergency conditions, to government or other groups that assist in emergencies or disasters.

• Clinic also may disclose or use your information without your consent in the following cases: when required by law; for public health activities; relation to victims of abuse/neglect/domestic violence, if required/authorized by law and or if you agree; for health oversight activities; for judicial and administrative proceedings to the extent permitted by law; for law enforcement purposes as permitted or required by law; to coroners/medicalexaminers/funeral directors, as permitted by law; for organ donation purposes, for research purposes under certain specialized government functions, such as military discharge, and national security and intelligence.

Clinic will not use or disclose your medical information in any other way unless you allow us to do so in writing. If you do give us permission to use or disclose your medical information for another purpose, you have the right to change your mind and revoke the permission at any time.

Your privacy rights:

• You may request that the Clinic use your medical information in certain ways or for certain purposes. You may also request that Clinic not provide your medical information to certain people. However, Clinic has the right to refuse your request, and Clinic may use or disclose your medical information in situations requiring emergency treatment, in which case we will ask the person(s) who receive the information not to further use or disclose the information.

• If you feel your medical information privacy rights have been violated, you may file a complaint with the Clinic Administrator listed below. Filing a complaint will not affect the quality of the services you receive from Clinic and you will not be retaliated against for filing a complaint.

• You can contact the designated privacy official at Clinic:

Name: James Rauzi

Title: Clinic Administrator

Phone Number 715-394-6355

CMJT Billing Information

• With your approval, we will bill your insurance company for services provided at CMJT. You will not receive a bill until the insurance has made their payment and indicated your balance responsibility.

Payments are to be made out to CMJT and can be paid at the office, by mail, or over the phone with a major credit card.