This notice describes how medical information about you may be used and disclosed. It also describes how you can get access to this information; please review it carefully.

The Health Insurance Portability & Accountability Act of 1996 (HIPPA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPPA” provides penalties for covered entities that misuse personal health information.

As required by HIPPA, I have prepared this explanation of how I am required to maintain the privacy of your health information and how I may use and disclose your health care operations.

  • Treatment means providing, coordinating, or managing health care and related services by one or more health care providers.
  • Payment means such activities as obtaining reimbursement for service, confirming coverage, billing or collection activities, and utilization review: an example of this would be sending a bill for your visit to your insurance company for payment.
  • Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis and customer services: an example would be an internal quality assessment review. I may also create and distribute de-identified health information by removing all references to individually identifiable information. Any other uses and disclosures will be made only with your written authorization except in instances required by law. You may revoke such authorization in writing and I am required to honor and abide by that written request, except to the extent that I have already taken actions relying on your authorization.

Your Privacy Rights

You have the following rights, with respect to, your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

A. The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. I am, however, not required to agree to a requested restriction. If I do agree to a restriction, I must abide by it unless you agree in writing to remove it.

B. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternate locations.

C. The right to inspect and copy your protected health information.

D. The right to amend your protected health information.

E. The right to receive an accounting of disclosures of protected health information.

F. The right to obtain a paper copy of this notice from us upon request.

I am required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices, with respect to protected health information. This notice is effective as of November 1999 and I am required to abide by the term of the Notice of Privacy Practices currently in effect. I reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that I maintain. I will post and you may request a written copy of a revised Notice of Privacy Practices from the Privacy Officer.

If you feel that your privacy rights have been violated, you may file a written complaint at the address listed below. Under no circumstances will the fact that you have filed a complaint affect the services provided to you.

Kristie Bennett P.T., M.S., C.L.T.

Pinnacle Physical Therapy, P.C.

3434 47th St. #107

Boulder, Co 80301