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Date Legal Name
(First) (Middle) (Last)
Preferred Pronoun: He/ Him She/Her They/Them Only My Name No Preference Pronoun not listed:
Chosen Name or Nickname Date of Birth
Sex listed on Insurance Male Female
Address:
(Street) (City) (State) (Zip Code)
Preferred method of communication: Cell Phone Home Phone Day Phone Email
Preferred Phone # To receive appointment reminder text messages, please check here
Consent to Email Communication
I agree to receive email communication regarding appointment updates and marketing communication from Athletico
Physical Therapy at the following email address:
What is your primary language? Do you need an interpreter? Yes No
You have the right to an interpreter at no cost. If you need these services, notify your Clinician or Office Coordinator.
Employer Name Employer phone
Employer Local Address
HR Department Contact HR Dept. phone
How did you hear of Athletico? (Please choose one below)
Advertisement Internet Athletico Website School Club Sport Performing Arts Insurance
Professional Sports Team Race Endurance Training Group Athletico Location/Signage Physician Referral
Other Please specify name/organization:
Consent to Verbal Communication
I give permission to the following person(s) to receive detailed verbal information regarding my appointments, medical
care, billing and payment information. I understand this DOES NOT authorize the disclosure of my written health
information.
Name Relationship
Name Relationship
I understand Athletico personnel may call my home phone number or other alternative number and leave a voice mail or in person in reference to
appointment reminders, insurance or billing items. I also authorize the release of appointment information left in a voice-mail, answering machine or
text message and understand that there is some level of privacy risk associated with these forms of communication.
Emergency Contact Information
Person to contact in case of an emergency:
____________________________________________ _________________________________________
Name Telephone Number Relationship
Physician Information
Referring Physician Phone
Address
Next physician appointment: Date Time
Do you have a Primary Care Physician? Yes No
If yes, would like us to send copies of correspondence to your primary care physician? Please complete:
Primary Care Physician Phone
Address
Insurance
Have you verified your therapy benefits with your insurance? Yes No
Have you had Physical/Occupational therapy this calendar year? Yes No
How many treatments (include Chiropractic) have you received this calendar year? _______ Former Patient? Yes No
Health Insurance
Primary Insurance Company ID# Group #
Policyholder name Relationship DOB
Secondary Insurance Company ID# Group #
Policyholder name Relationship DOB
Auto Accident / Personal Injury
Is this an Auto Accident? Yes No Is this a Personal Injury? Yes No
Date of Accident
In what City and State did this occur? Is this a lawsuit? Yes No
Attorney/Firm Name Attorney Phone
Work Comp
Is this an approved Workers Comp Injury? Yes No Date of Injury
In what City and State did the injury occur? Job Title
Attorney/Firm Name Attorney Phone
*Please make sure Employer information is filled out on previous page.
Medical History
Age Height Weight
What problem(s) are you being treated for today? Describe type and location of symptoms
What date (roughly) did your present symptoms start?
My symptoms are currently: Getting Better Getting Worse Staying the Same
My symptoms currently: Come and go Are Constant Constant, but change with activity
What makes your symptoms better?
What makes your symptoms worse?
What time of the day are your symptoms worse?: Morning Afternoon Evening Overnight
Have you recently noted any of the following? (Check all that apply)
□ Changes in bowel or
bladder function
□ Shortness of breath
□ Nausea/vomiting
□ Weakness/fatigue
□ Headaches
□ Difficulty maintaining
balance while
walking
□ Difficulty swallowing
□ Weight loss/gain
□ Numbness/tingling
□ Fever/chills/sweats
□ Pain at night
□ Dizziness
□ Lightheadedness
□ Changes in appetite
Treatment received so far for this problem: Chiropractic Acupuncture Injections
Physical/Occupational therapy Other
Special Tests done: X-Ray Bone Scan CT Scan MRI
If you have any questions, please contact: 1-877-ATHLETICO | email: info@athletico.com
List past Medical History (i.e. falls, surgeries, pacemaker) including dates (indicate if for current condition)
List any allergies (i.e. latex, adhesives)
Medications Are you currently taking any medications, herbals, vitamins, supplements? Yes No
If yes please list below.
Medication Name How much (dose) How often How taken (circle one)
________________ _____________ _________ ointment pill drop patch injection inhaler
________________ _____________ _________ ointment pill drop patch injection inhaler
________________ _____________ _________ ointment pill drop patch injection inhaler
________________ _____________ _________ ointment pill drop patch injection inhaler
List any medications you are allergic to and your reaction
Are you pregnant? If yes, how many weeks? ___________ Have you experienced pregnancy related pain?
Have you utilized tobacco in the last 12 months? (Check one) Yes No
ONLY for patients 12-20 years old. If you answered no above, have you ever utilized tobacco? Yes No
Do you drink alcohol? Yes No # of drinks per week:
Over the past 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things: Not at all Several Days More than one half of days Nearly every day
Feeling down, depressed, or hopeless: Not at all Several Days More than one half of days Nearly every day
Fall History
Number of falls within the last year? 0 1 2+
Did a fall result in injury? Yes No
Are you suffering from abuse (ex: physical, emotional, psychological), neglect, abandonment, material exploitation, or
unwarranted control? Yes No
Pelvic Health Question
If you are experiencing any of the problems listed below, please check the box and your therapist can discuss potential
treatment options with you. Do you have a history of pelvic disorders (i.e. urge/stress incontinence, pelvic floor heaviness,
pelvic/bladder or abdominal pain, irregular bowel movements)? Yes
Social History/Leisure Activities/Exercise Routine
Home House Condo/Apartment Group Residence Nursing Home
Do you live alone: Yes No
Are you currently working: Full Duty Light Duty Not working If not working, date last worked
Athletico Physical Therapy complies with applicable Federal civil rights laws and does not discriminate on the basis of race, age, religion, sex,
national origin, socioeconomic status, sexual orientation, gender identity or expression, disability, veteran status, or source of payment. You
will be treated with dignity, compassion, and respect as an individual.
04/01/21
Updated 04/01/21
Consent and Statement
of Financial Responsibility
4/25/2019
If you have any questions, please contact the Athletico Corporate office:
625 Enterprise Drive, Oak Brook, IL 60523 | tel: 630.575.6200 | 1.877.ATHLETICO | email: info@athletico.com
4/17/18
CONSENT AND STATEMENT OF FINANCIAL RESPONSIBILITY
1.
CONSENT FOR TREATMENT: I hereby consent to, and authorize my physical therapist, occupational therapist and other health care
professionals and assistants who may be involved in my care, to provide care and treatment prescribed by my physician and/or considered
necessary or advisable by my physician, physical therapist, occupational therapist or other healthcare professionals. .I understand that a
physical therapy diagnosis is not a medical diagnosis by a physician. I understand that my treatment may include techniques that can result in
bruising, reddening of the skin, soreness after treatment and hematoma, including, without limitation, myofascial decompression and blood
flow restriction, Assisted Soft Tissue M obilization, Asytm ® or Graston Technique®, Video Throwing Analysis and Video Gait Analysis. I
understand that it is my responsibility to inform my physical therapist, occupational therapist or other health care professional if I experience
any discomfort or pain during any treatment or if I have other unresolved concerns around my treatment. I understand that response to
physical therapy intervention varies from person to person and it is possible that treatment may result in aggravation of existing symptoms or
may cause pain or injury.
2. APPOINTMENT ATTENDANCE AGREEMENT: I understand the importance of attending therapy consistently, scheduling appointments in
advance and arriving promptly for my appointment. I acknowledge that I may be rescheduled if I arrive more than 15 minutes late for my
scheduled appointment. I understand and acknowledge that appointment times given one week may not be available in subsequent weeks. I
agree to provide at least 24 hours’ notice when I need to cancel or reschedule an appointment and I understand that cancellation of, or failing
to keep, an appointment with less than 24 hours’ notice will result in a cancel/no show fee of $30 or $60 depending on appointment type.
WORKER’S COMPENSATION PATIENTS: I understand that Athletico is required to inform my Worker’s Compensation
Adjuster and/or Rehabilitation M anager of all missed or canceled appointments. I understand that any missed visits must be
rescheduled.
3. RESPONSIBILITY FOR PAYMENT: All co-payments and self –pay services (i.e., Astym, Graston, VGA, VTA, etc.) are due at the time of
service. I acknowledge that in consideration of the services provided to me by Athletico, I am financially responsible for payment of my bill. I
acknowledge that it is my responsibility to provide Athletico with my current insurance information and to familiarize myself with m y insurance
plan and its policies. Any questions I have regarding my health insurance coverage or benefit levels should be directed to my health plan. M y
health insurance plan may provide that all or a portion of the charges and balance will remain my personal responsibility, such as my
deductible, co-payment, co-insurance or charges not covered or denied by my health insurance, M edicare, or other programs for which I am
eligible. I agree to pay any such amounts which are my responsibility. I understand that Athletico will bill my personal insurance carrier as a
courtesy, but that I am ultimately responsible for any amounts owed. If formal collection procedures become necessary, I am responsible for
any additional costs incurred as a result of such collection procedures.
If I pay any amount with a check, I hereby authorize Athletico to use the information from the check to process a one-time Electronic Funds
Transfer (EFT/ACH) or a draft drawn from my account. I understand that if my payment is processed as an EFT, funds may be withdrawn
from my account as soon as the same day and I will not receive my check back from my financial institu tion.
Please note that refusal to sign this form does not change responsibility for payment in any way.
4. ASSIGNMENT OF BENEFITS: I hereby assign to Athletico all my rights and claims for reimbursement under my health insurance policy. I
agree to cooperate with Athletico and to provide such information as is needed to establish my eligibility for such benefits.
5. ACCESS TO AND RELEASE OF HEALTH INFORMATION: I understand that Athletico may document medical and other information
related to my treatment in electronic and other forms and that such information will be used in the course of my treatment, for payment
purposes and to support those who are caring for me. I authorize my clinician(s) and Athletico’s administrative staff to contact other
healthcare professionals that may have information related to my prior and current health conditions and treatment. I acknowledge that I have
received Athletico’s Notice of Privacy Practices and that it outlines how my health information may be used and disclosed and how I may gain
access to and control my health information.
I acknowledge that I have received Athletico’s Notice of Privacy Practices and that it outlines how my health information may be
used and disclosed and how I may gain access to and control my health information. (Please check box)
By my signature below, I certify that I have read, understand, and fully agree to each of the statements in this document and sign below freely
and voluntarily.
________________________________________________
Printed Name of Patient
________________________________________________ _________________________
Signature of Patient or Legally Responsible Person Date
_______________________________________________ _ _________________________
Printed Name of above (if not the Patient) Date
Athletico complies with applicable civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
If you have any questions, please contact the Athletico Resource Center:
625 Enterprise Drive, Oak Brook, IL 60523|tel: 630.575.6200|1.877.ATHLETICO|email: info@athletico.com
Updated 07/03/18
If you have any questions, please contact: 1-877-ATHLETICO | email: info@athletico.com
4/26/19
click to sign
signature
click to edit
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Your information. Your rights.
Our responsibilities.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
When it comes to your health information, you have certain rights. This section explains your rights and how to exercise them.
Your Rights
Receive an electronic or paper copy of your medical record
• You can ask to see or receive an electronic or paper copy of your
medical record. You may submit your request in writing.
• We will provide a copy or a summary of your health information within
30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct or amend your medical record
• You can ask us in writing to correct health information about you that
you think is incorrect or incomplete.
• We may say “no” to your request, but we will tell you why in writing.
Request confidential communications
• You can ask us to contact you in a specific way (for example, cell
phone) or to send mail to a different address. We will accommodate
all reasonable requests.
Ask us to restrict or limit what we use or share
• You can ask us not to use or share certain health information for
treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no” if
it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you
can ask us not to share that information for the purpose of payment
or our operations with your health insurer.
• We will say “yes” unless a law requires us to share that information.
Ask for a list of certain disclosures with whom we’ve
shared information
• You may ask for a list of certain disclosures of your health information made
by us, if any. This list will not include disclosures, about treatment, payment,
or health care operations and certain other disclosures you may have asked
us to make.
• We will include all disclosures of health information for six years prior to the
date you ask.
• We will provide this to you once per year for free but will charge a
reasonable, cost-based fee if you ask for another one within 12 months.
Obtain a copy of this privacy notice
• You can ask for a paper copy of this Notice at any time, even if you have
agreed to receive the Notice electronically. We will provide you with a paper
copy promptly.
Notification of a breach
• We will notify you if there is a breach of your health information.
Help manage the health care treatment you receive
• We may use your health information in the provision and
coordination of your health care. For example, your physical
therapist may disclose your health information when consulting
with your primary care physician regarding your medical condition.
Payment
• We can use and disclose your health information to bill and receive
payment for your healthcare services.
For example, we may contact your insurer to get paid for services that
we delivered to you.
Health care operations
• We may use or disclose your health information to monitor and
support the operation of our facilities.
For example, evaluating the quality of services provided, performing
licensing and credentialing activities and other administrative functions.
Patient contact
• We may contact you to set up or remind you about future
appointments, billing or payment matters.
Your Information. Your Rights.
Our Responsibilities.
We may, without your written authorization use and disclose your health information for the following purposes:
Our Uses and Disclosures
Protecting your health information is important to us
• We are required by law to maintain the privacy and security of your
protected health information. We must follow the duties and privacy
practices described in this notice.
• If you are concerned that we have violated your privacy rights, you may
contact our Privacy Officer by calling 630-575-1962 or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/. You may also file a written
complaint with the Secretary of the U.S. Department of Health and
Human Services. There will be no retaliation for filing a complaint.
• If you wish to exercise any of your rights above, you may submit a
written request. Forms will be available upon request at any of our
facilities, or by calling the contact number at the end of this Notice.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
When it comes to your health information, you have certain rights. This section explains your rights and how to exercise them.
Your Rights
Receive an electronic or paper copy of your medical record
• You can ask to see or receive an electronic or paper copy of your
medical record. You may submit your request in writing.
• We will provide a copy or a summary of your health information within
30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct or amend your medical record
• You can ask us in writing to correct health information about you that
you think is incorrect or incomplete.
• We may say “no” to your request, but we will tell you why in writing.
Request confidential communications
• You can ask us to contact you in a specific way (for example, cell
phone) or to send mail to a different address. We will accommodate
all reasonable requests.
Ask us to restrict or limit what we use or share
• You can ask us not to use or share certain health information for
treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no” if
it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you
can ask us not to share that information for the purpose of payment
or our operations with your health insurer.
• We will say “yes” unless a law requires us to share that information.
Ask for a list of certain disclosures with whom we’ve
shared information
• You may ask for a list of certain disclosures of your health information made
by us, if any. This list will not include disclosures, about treatment, payment,
or health care operations and certain other disclosures you may have asked
us to make.
• We will include all disclosures of health information for six years prior to the
date you ask.
• We will provide this to you once per year for free but will charge a
reasonable, cost-based fee if you ask for another one within 12 months.
Obtain a copy of this privacy notice
• You can ask for a paper copy of this Notice at any time, even if you have
agreed to receive the Notice electronically. We will provide you with a paper
copy promptly.
Notification of a breach
• We will notify you if there is a breach of your health information.
Help manage the health care treatment you receive
• We may use your health information in the provision and
coordination of your health care. For example, your physical
therapist may disclose your health information when consulting
with your primary care physician regarding your medical condition.
Payment
• We can use and disclose your health information to bill and receive
payment for your healthcare services.
For example, we may contact your insurer to get paid for services that
we delivered to you.
Health care operations
• We may use or disclose your health information to monitor and
support the operation of our facilities.
For example, evaluating the quality of services provided, performing
licensing and credentialing activities and other administrative functions.
Patient contact
• We may contact you to set up or remind you about future
appointments, billing or payment matters.
Your Information. Your Rights.
Our Responsibilities.
We may, without your written authorization use and disclose your health information for the following purposes:
Our Uses and Disclosures
Protecting your health information is important to us
• We are required by law to maintain the privacy and security of your
protected health information. We must follow the duties and privacy
practices described in this notice.
• If you are concerned that we have violated your privacy rights, you may
contact our Privacy Officer by calling 630-575-1962 or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/. You may also file a written
complaint with the Secretary of the U.S. Department of Health and
Human Services. There will be no retaliation for filing a complaint.
• If you wish to exercise any of your rights above, you may submit a
written request. Forms will be available upon request at any of our
facilities, or by calling the contact number at the end of this Notice.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
When it comes to your health information, you have certain rights. This section explains your rights and how to exercise them.
Your Rights
Receive an electronic or paper copy of your medical record
• You can ask to see or receive an electronic or paper copy of your
medical record. You may submit your request in writing.
• We will provide a copy or a summary of your health information within
30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct or amend your medical record
• You can ask us in writing to correct health information about you that
you think is incorrect or incomplete.
• We may say “no” to your request, but we will tell you why in writing.
Request confidential communications
• You can ask us to contact you in a specific way (for example, cell
phone) or to send mail to a different address. We will accommodate
all reasonable requests.
Ask us to restrict or limit what we use or share
• You can ask us not to use or share certain health information for
treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no” if
it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you
can ask us not to share that information for the purpose of payment
or our operations with your health insurer.
• We will say “yes” unless a law requires us to share that information.
Ask for a list of certain disclosures with whom we’ve
shared information
• You may ask for a list of certain disclosures of your health information made
by us, if any. This list will not include disclosures, about treatment, payment,
or health care operations and certain other disclosures you may have asked
us to make.
• We will include all disclosures of health information for six years prior to the
date you ask.
• We will provide this to you once per year for free but will charge a
reasonable, cost-based fee if you ask for another one within 12 months.
Obtain a copy of this privacy notice
• You can ask for a paper copy of this Notice at any time, even if you have
agreed to receive the Notice electronically. We will provide you with a paper
copy promptly.
Notification of a breach
• We will notify you if there is a breach of your health information.
Help manage the health care treatment you receive
• We may use your health information in the provision and
coordination of your health care. For example, your physical
therapist may disclose your health information when consulting
with your primary care physician regarding your medical condition.
Payment
• We can use and disclose your health information to bill and receive
payment for your healthcare services.
For example, we may contact your insurer to get paid for services that
we delivered to you.
Health care operations
• We may use or disclose your health information to monitor and
support the operation of our facilities.
For example, evaluating the quality of services provided, performing
licensing and credentialing activities and other administrative functions.
Patient contact
• We may contact you to set up or remind you about future
appointments, billing or payment matters.
Your Information. Your Rights.
Our Responsibilities.
We may, without your written authorization use and disclose your health information for the following purposes:
Our Uses and Disclosures
Protecting your health information is important to us
• We are required by law to maintain the privacy and security of your
protected health information. We must follow the duties and privacy
practices described in this notice.
• If you are concerned that we have violated your privacy rights, you may
contact our Privacy Officer by calling 630-575-1962 or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/. You may also file a written
complaint with the Secretary of the U.S. Department of Health and
Human Services. There will be no retaliation for filing a complaint.
• If you wish to exercise any of your rights above, you may submit a
written request. Forms will be available upon request at any of our
facilities, or by calling the contact number at the end of this Notice.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
When it comes to your health information, you have certain rights. This section explains your rights and how to exercise them.
Your Rights
Receive an electronic or paper copy of your medical record
• You can ask to see or receive an electronic or paper copy of your
medical record. You may submit your request in writing.
• We will provide a copy or a summary of your health information within
30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct or amend your medical record
• You can ask us in writing to correct health information about you that
you think is incorrect or incomplete.
• We may say “no” to your request, but we will tell you why in writing.
Request confidential communications
• You can ask us to contact you in a specific way (for example, cell
phone) or to send mail to a different address. We will accommodate
all reasonable requests.
Ask us to restrict or limit what we use or share
• You can ask us not to use or share certain health information for
treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no” if
it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you
can ask us not to share that information for the purpose of payment
or our operations with your health insurer.
• We will say “yes” unless a law requires us to share that information.
Ask for a list of certain disclosures with whom we’ve
shared information
• You may ask for a list of certain disclosures of your health information made
by us, if any. This list will not include disclosures, about treatment, payment,
or health care operations and certain other disclosures you may have asked
us to make.
• We will include all disclosures of health information for six years prior to the
date you ask.
• We will provide this to you once per year for free but will charge a
reasonable, cost-based fee if you ask for another one within 12 months.
Obtain a copy of this privacy notice
• You can ask for a paper copy of this Notice at any time, even if you have
agreed to receive the Notice electronically. We will provide you with a paper
copy promptly.
Notification of a breach
• We will notify you if there is a breach of your health information.
Help manage the health care treatment you receive
• We may use your health information in the provision and
coordination of your health care. For example, your physical
therapist may disclose your health information when consulting
with your primary care physician regarding your medical condition.
Payment
• We can use and disclose your health information to bill and receive
payment for your healthcare services.
For example, we may contact your insurer to get paid for services that
we delivered to you.
Health care operations
• We may use or disclose your health information to monitor and
support the operation of our facilities.
For example, evaluating the quality of services provided, performing
licensing and credentialing activities and other administrative functions.
Patient contact
• We may contact you to set up or remind you about future
appointments, billing or payment matters.
Your Information. Your Rights.
Our Responsibilities.
We may, without your written authorization use and disclose your health information for the following purposes:
Our Uses and Disclosures
Protecting your health information is important to us
• We are required by law to maintain the privacy and security of your
protected health information. We must follow the duties and privacy
practices described in this notice.
• If you are concerned that we have violated your privacy rights, you may
contact our Privacy Officer by calling 630-575-1962 or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/. You may also file a written
complaint with the Secretary of the U.S. Department of Health and
Human Services. There will be no retaliation for filing a complaint.
• If you wish to exercise any of your rights above, you may submit a
written request. Forms will be available upon request at any of our
facilities, or by calling the contact number at the end of this Notice.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
When it comes to your health information, you have certain rights. This section explains your rights and how to exercise them.
Your Rights
Receive an electronic or paper copy of your medical record
• You can ask to see or receive an electronic or paper copy of your
medical record. You may submit your request in writing.
• We will provide a copy or a summary of your health information within
30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct or amend your medical record
• You can ask us in writing to correct health information about you that
you think is incorrect or incomplete.
• We may say “no” to your request, but we will tell you why in writing.
Request confidential communications
• You can ask us to contact you in a specific way (for example, cell
phone) or to send mail to a different address. We will accommodate
all reasonable requests.
Ask us to restrict or limit what we use or share
• You can ask us not to use or share certain health information for
treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no” if
it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you
can ask us not to share that information for the purpose of payment
or our operations with your health insurer.
• We will say “yes” unless a law requires us to share that information.
Ask for a list of certain disclosures with whom we’ve
shared information
• You may ask for a list of certain disclosures of your health information made
by us, if any. This list will not include disclosures, about treatment, payment,
or health care operations and certain other disclosures you may have asked
us to make.
• We will include all disclosures of health information for six years prior to the
date you ask.
• We will provide this to you once per year for free but will charge a
reasonable, cost-based fee if you ask for another one within 12 months.
Obtain a copy of this privacy notice
• You can ask for a paper copy of this Notice at any time, even if you have
agreed to receive the Notice electronically. We will provide you with a paper
copy promptly.
Notification of a breach
• We will notify you if there is a breach of your health information.
Help manage the health care treatment you receive
• We may use your health information in the provision and
coordination of your health care. For example, your physical
therapist may disclose your health information when consulting
with your primary care physician regarding your medical condition.
Payment
• We can use and disclose your health information to bill and receive
payment for your healthcare services.
For example, we may contact your insurer to get paid for services that
we delivered to you.
Health care operations
• We may use or disclose your health information to monitor and
support the operation of our facilities.
For example, evaluating the quality of services provided, performing
licensing and credentialing activities and other administrative functions.
Patient contact
• We may contact you to set up or remind you about future
appointments, billing or payment matters.
Your Information. Your Rights.
Our Responsibilities.
We may, without your written authorization use and disclose your health information for the following purposes:
Our Uses and Disclosures
Protecting your health information is important to us
• We are required by law to maintain the privacy and security of your
protected health information. We must follow the duties and privacy
practices described in this notice.
• If you are concerned that we have violated your privacy rights, you may
contact our Privacy Officer by calling 630-575-1962 or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/. You may also file a written
complaint with the Secretary of the U.S. Department of Health and
Human Services. There will be no retaliation for filing a complaint.
• If you wish to exercise any of your rights above, you may submit a
written request. Forms will be available upon request at any of our
facilities, or by calling the contact number at the end of this Notice.
Our Uses and Disclosures cont’d:
Family members and others involved in your care
• Unless you object, we may disclose relevant health information to a family
member, relative or close friend who is involved in your care or in payment
of your care.
For example, we may share information with a family member to help you
understand your care, handle your bills, or schedule appointments.
Workers’ compensation
• We may disclose your 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. These
programs provide benefits for work-related injuries or illnesses.
As required by law
• We may disclose health information about you when required by
federal, state or local law.
Health oversight activities
• We may use or disclose health information about you with health
oversight agencies for activities authorized by law.
For example, oversight activities may include audits, investigations
and inspections necessary for the government to monitor the health
care system.
Marketing communications
• We may use and disclose your health information to contact you with
information about treatment services, products or new locations that we
believe might be of interest to you.
Research
• We may use your health information for research purposes in certain
circumstances with your authorization.
Public health and safety issues
• We may share your health information for certain situations such as,
preventing disease, reporting suspected abuse, neglect, or domestic violence,
preventing or reducing a serious threat to anyone’s health or safety.
Law enforcement and specialized government functions
• We may disclose your health information for law enforcement purposes
as permitted by law. Under certain circumstances, we may disclose
health information to units of the government with specialized functions
such as the U.S. Military in response to requests as authorized by law.
Respond to lawsuits and legal actions
• We may share health information about you in response to a court or
administrative order, or in response to a subpoena or similar legal request.
To business associates
• We may disclose your health information to our “business associates” -
individuals or companies that provide services for Athletico.
For example, a business associate would include the company that
administers the billing claims for Athletico. In all cases, we require business
associates to appropriately safeguard the privacy of your information.
To Parents and legal guardians of minors
• As permitted by federal and state law, we may disclose health
information about minors to their parents or guardians.
Highly confidential information
• Federal and state laws provide additional privacy protection for certain
confidential health information. This includes information dealing with
mental health, HIV/AIDS, alcohol and drug abuse treatment.
Our Uses and Disclosures cont’d:
Uses and disclosures pursuant to an authorization
Other uses and disclosures of your protected health information, not described above, will be made only with your written authorization. You may revoke
your authorization, in writing, at any time, except that a revocation will not affect any uses or disclosures we have made in reliance on such authorization.
Changes to the terms of this notice
We can change the terms of this Notice and the changes will apply to all information we have about you. The new Notice will be available upon
request, posted at each of our facilities and our web site at athletico.com.
If you have any questions, or would like to discuss this Notice in more detail, please contact the privacy officer at 630-575-1962 or
compliance@athletico.com. This Notice is effective as of April 1, 2018.
This Notice of Privacy Practices applies to Athletico Holdings, LLC and its subsidiaries and controlled affiliates (including, without limitation, Athletico,
Ltd. and its subsidiaries)(collectively,”Athletico”). Please visit our website for a full listing of all Athletico locations.
Family members and others involved in your care
• Unless you object, we may disclose relevant health information to a family
member, relative or close friend who is involved in your care or in payment
of your care.
For example, we may share information with a family member to help you
understand your care, handle your bills, or schedule appointments.
Workers’ compensation
• We may disclose your 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. These
programs provide benefits for work-related injuries or illnesses.
As required by law
• We may disclose health information about you when required by
federal, state or local law.
Health oversight activities
• We may use or disclose health information about you with health
oversight agencies for activities authorized by law.
For example, oversight activities may include audits, investigations
and inspections necessary for the government to monitor the health
care system.
Marketing communications
• We may use and disclose your health information to contact you with
information about treatment services, products or new locations that we
believe might be of interest to you.
Research
• We may use your health information for research purposes in certain
circumstances with your authorization.
Public health and safety issues
• We may share your health information for certain situations such as,
preventing disease, reporting suspected abuse, neglect, or domestic violence,
preventing or reducing a serious threat to anyone’s health or safety.
Law enforcement and specialized government functions
• We may disclose your health information for law enforcement purposes
as permitted by law. Under certain circumstances, we may disclose
health information to units of the government with specialized functions
such as the U.S. Military in response to requests as authorized by law.
Respond to lawsuits and legal actions
• We may share health information about you in response to a court or
administrative order, or in response to a subpoena or similar legal request.
To business associates
• We may disclose your health information to our “business associates” -
individuals or companies that provide services for Athletico.
For example, a business associate would include the company that
administers the billing claims for Athletico. In all cases, we require business
associates to appropriately safeguard the privacy of your information.
To Parents and legal guardians of minors
• As permitted by federal and state law, we may disclose health
information about minors to their parents or guardians.
Highly confidential information
• Federal and state laws provide additional privacy protection for certain
confidential health information. This includes information dealing with
mental health, HIV/AIDS, alcohol and drug abuse treatment.
Our Uses and Disclosures cont’d:
Uses and disclosures pursuant to an authorization
Other uses and disclosures of your protected health information, not described above, will be made only with your written authorization. You may revoke
your authorization, in writing, at any time, except that a revocation will not affect any uses or disclosures we have made in reliance on such authorization.
Changes to the terms of this notice
We can change the terms of this Notice and the changes will apply to all information we have about you. The new Notice will be available upon
request, posted at each of our facilities and our web site at athletico.com.
If you have any questions, or would like to discuss this Notice in more detail, please contact the privacy officer at 630-575-1962 or
compliance@athletico.com. This Notice is effective as of April 1, 2018.
This Notice of Privacy Practices applies to Athletico Holdings, LLC and its subsidiaries and controlled affiliates (including, without limitation, Athletico,
Ltd. and its subsidiaries)(collectively,”Athletico”). Please visit our website for a full listing of all Athletico locations.
Family members and others involved in your care
• Unless you object, we may disclose relevant health information to a family
member, relative or close friend who is involved in your care or in payment
of your care.
For example, we may share information with a family member to help you
understand your care, handle your bills, or schedule appointments.
Workers’ compensation
• We may disclose your 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. These
programs provide benefits for work-related injuries or illnesses.
As required by law
• We may disclose health information about you when required by
federal, state or local law.
Health oversight activities
• We may use or disclose health information about you with health
oversight agencies for activities authorized by law.
For example, oversight activities may include audits, investigations
and inspections necessary for the government to monitor the health
care system.
Marketing communications
• We may use and disclose your health information to contact you with
information about treatment services, products or new locations that we
believe might be of interest to you.
Research
• We may use your health information for research purposes in certain
circumstances with your authorization.
Public health and safety issues
• We may share your health information for certain situations such as,
preventing disease, reporting suspected abuse, neglect, or domestic violence,
preventing or reducing a serious threat to anyone’s health or safety.
Law enforcement and specialized government functions
• We may disclose your health information for law enforcement purposes
as permitted by law. Under certain circumstances, we may disclose
health information to units of the government with specialized functions
such as the U.S. Military in response to requests as authorized by law.
Respond to lawsuits and legal actions
• We may share health information about you in response to a court or
administrative order, or in response to a subpoena or similar legal request.
To business associates
• We may disclose your health information to our “business associates” -
individuals or companies that provide services for Athletico.
For example, a business associate would include the company that
administers the billing claims for Athletico. In all cases, we require business
associates to appropriately safeguard the privacy of your information.
To Parents and legal guardians of minors
• As permitted by federal and state law, we may disclose health
information about minors to their parents or guardians.
Highly confidential information
• Federal and state laws provide additional privacy protection for certain
confidential health information. This includes information dealing with
mental health, HIV/AIDS, alcohol and drug abuse treatment.
Our Uses and Disclosures cont’d:
Uses and disclosures pursuant to an authorization
Other uses and disclosures of your protected health information, not described above, will be made only with your written authorization. You may revoke
your authorization, in writing, at any time, except that a revocation will not affect any uses or disclosures we have made in reliance on such authorization.
Changes to the terms of this notice
We can change the terms of this Notice and the changes will apply to all information we have about you. The new Notice will be available upon
request, posted at each of our facilities and our web site at athletico.com.
If you have any questions, or would like to discuss this Notice in more detail, please contact the privacy officer at 630-575-1962 or
compliance@athletico.com. This Notice is effective as of April 1, 2018.
This Notice of Privacy Practices applies to Athletico Holdings, LLC and its subsidiaries and controlled affiliates (including, without limitation, Athletico,
Ltd. and its subsidiaries)(collectively,”Athletico”). Please visit our website for a full listing of all Athletico locations.
Family members and others involved in your care
• Unless you object, we may disclose relevant health information to a family
member, relative or close friend who is involved in your care or in payment
of your care.
For example, we may share information with a family member to help you
understand your care, handle your bills, or schedule appointments.
Workers’ compensation
• We may disclose your 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. These
programs provide benefits for work-related injuries or illnesses.
As required by law
• We may disclose health information about you when required by
federal, state or local law.
Health oversight activities
• We may use or disclose health information about you with health
oversight agencies for activities authorized by law.
For example, oversight activities may include audits, investigations
and inspections necessary for the government to monitor the health
care system.
Marketing communications
• We may use and disclose your health information to contact you with
information about treatment services, products or new locations that we
believe might be of interest to you.
Research
• We may use your health information for research purposes in certain
circumstances with your authorization.
Public health and safety issues
• We may share your health information for certain situations such as,
preventing disease, reporting suspected abuse, neglect, or domestic violence,
preventing or reducing a serious threat to anyone’s health or safety.
Law enforcement and specialized government functions
• We may disclose your health information for law enforcement purposes
as permitted by law. Under certain circumstances, we may disclose
health information to units of the government with specialized functions
such as the U.S. Military in response to requests as authorized by law.
Respond to lawsuits and legal actions
• We may share health information about you in response to a court or
administrative order, or in response to a subpoena or similar legal request.
To business associates
• We may disclose your health information to our “business associates” -
individuals or companies that provide services for Athletico.
For example, a business associate would include the company that
administers the billing claims for Athletico. In all cases, we require business
associates to appropriately safeguard the privacy of your information.
To Parents and legal guardians of minors
• As permitted by federal and state law, we may disclose health
information about minors to their parents or guardians.
Highly confidential information
• Federal and state laws provide additional privacy protection for certain
confidential health information. This includes information dealing with
mental health, HIV/AIDS, alcohol and drug abuse treatment.
Our Uses and Disclosures cont’d:
Uses and disclosures pursuant to an authorization
Other uses and disclosures of your protected health information, not described above, will be made only with your written authorization. You may revoke
your authorization, in writing, at any time, except that a revocation will not affect any uses or disclosures we have made in reliance on such authorization.
Changes to the terms of this notice
We can change the terms of this Notice and the changes will apply to all information we have about you. The new Notice will be available upon
request, posted at each of our facilities and our web site at athletico.com.
If you have any questions, or would like to discuss this Notice in more detail, please contact the privacy officer at 630-575-1962 or
compliance@athletico.com. This Notice is effective as of April 1, 2018.
This Notice of Privacy Practices applies to Athletico Holdings, LLC and its subsidiaries and controlled affiliates (including, without limitation, Athletico,
Ltd. and its subsidiaries)(collectively,”Athletico”). Please visit our website for a full listing of all Athletico locations.
Family members and others involved in your care
• Unless you object, we may disclose relevant health information to a family
member, relative or close friend who is involved in your care or in payment
of your care.
For example, we may share information with a family member to help you
understand your care, handle your bills, or schedule appointments.
Workers’ compensation
• We may disclose your 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. These
programs provide benefits for work-related injuries or illnesses.
As required by law
• We may disclose health information about you when required by
federal, state or local law.
Health oversight activities
• We may use or disclose health information about you with health
oversight agencies for activities authorized by law.
For example, oversight activities may include audits, investigations
and inspections necessary for the government to monitor the health
care system.
Marketing communications
• We may use and disclose your health information to contact you with
information about treatment services, products or new locations that we
believe might be of interest to you.
Research
• We may use your health information for research purposes in certain
circumstances with your authorization.
Public health and safety issues
• We may share your health information for certain situations such as,
preventing disease, reporting suspected abuse, neglect, or domestic violence,
preventing or reducing a serious threat to anyone’s health or safety.
Law enforcement and specialized government functions
• We may disclose your health information for law enforcement purposes
as permitted by law. Under certain circumstances, we may disclose
health information to units of the government with specialized functions
such as the U.S. Military in response to requests as authorized by law.
Respond to lawsuits and legal actions
• We may share health information about you in response to a court or
administrative order, or in response to a subpoena or similar legal request.
To business associates
• We may disclose your health information to our “business associates” -
individuals or companies that provide services for Athletico.
For example, a business associate would include the company that
administers the billing claims for Athletico. In all cases, we require business
associates to appropriately safeguard the privacy of your information.
To Parents and legal guardians of minors
• As permitted by federal and state law, we may disclose health
information about minors to their parents or guardians.
Highly confidential information
• Federal and state laws provide additional privacy protection for certain
confidential health information. This includes information dealing with
mental health, HIV/AIDS, alcohol and drug abuse treatment.
Our Uses and Disclosures cont’d:
Uses and disclosures pursuant to an authorization
Other uses and disclosures of your protected health information, not described above, will be made only with your written authorization. You may revoke
your authorization, in writing, at any time, except that a revocation will not affect any uses or disclosures we have made in reliance on such authorization.
Changes to the terms of this notice
We can change the terms of this Notice and the changes will apply to all information we have about you. The new Notice will be available upon
request, posted at each of our facilities and our web site at athletico.com.
If you have any questions, or would like to discuss this Notice in more detail, please contact the privacy officer at 630-575-1962 or
compliance@athletico.com. This Notice is effective as of April 1, 2018.
This Notice of Privacy Practices applies to Athletico Holdings, LLC and its subsidiaries and controlled affiliates (including, without limitation, Athletico,
Ltd. and its subsidiaries)(collectively,”Athletico”). Please visit our website for a full listing of all Athletico locations.
Family members and others involved in your care
• Unless you object, we may disclose relevant health information to a family
member, relative or close friend who is involved in your care or in payment
of your care.
For example, we may share information with a family member to help you
understand your care, handle your bills, or schedule appointments.
Workers’ compensation
• We may disclose your 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. These
programs provide benefits for work-related injuries or illnesses.
As required by law
• We may disclose health information about you when required by
federal, state or local law.
Health oversight activities
• We may use or disclose health information about you with health
oversight agencies for activities authorized by law.
For example, oversight activities may include audits, investigations
and inspections necessary for the government to monitor the health
care system.
Marketing communications
• We may use and disclose your health information to contact you with
information about treatment services, products or new locations that we
believe might be of interest to you.
Research
• We may use your health information for research purposes in certain
circumstances with your authorization.
Public health and safety issues
• We may share your health information for certain situations such as,
preventing disease, reporting suspected abuse, neglect, or domestic violence,
preventing or reducing a serious threat to anyone’s health or safety.
Law enforcement and specialized government functions
• We may disclose your health information for law enforcement purposes
as permitted by law. Under certain circumstances, we may disclose
health information to units of the government with specialized functions
such as the U.S. Military in response to requests as authorized by law.
Respond to lawsuits and legal actions
• We may share health information about you in response to a court or
administrative order, or in response to a subpoena or similar legal request.
To business associates
• We may disclose your health information to our “business associates” -
individuals or companies that provide services for Athletico.
For example, a business associate would include the company that
administers the billing claims for Athletico. In all cases, we require business
associates to appropriately safeguard the privacy of your information.
To Parents and legal guardians of minors
• As permitted by federal and state law, we may disclose health
information about minors to their parents or guardians.
Highly confidential information
• Federal and state laws provide additional privacy protection for certain
confidential health information. This includes information dealing with
mental health, HIV/AIDS, alcohol and drug abuse treatment.
Our Uses and Disclosures cont’d:
Uses and disclosures pursuant to an authorization
Other uses and disclosures of your protected health information, not described above, will be made only with your written authorization. You may revoke
your authorization, in writing, at any time, except that a revocation will not affect any uses or disclosures we have made in reliance on such authorization.
Changes to the terms of this notice
We can change the terms of this Notice and the changes will apply to all information we have about you. The new Notice will be available upon
request, posted at each of our facilities and our web site at athletico.com.
If you have any questions, or would like to discuss this Notice in more detail, please contact the privacy officer at 630-575-1962 or
compliance@athletico.com. This Notice is effective as of April 1, 2018.
This Notice of Privacy Practices applies to Athletico Holdings, LLC and its subsidiaries and controlled affiliates (including, without limitation, Athletico,
Ltd. and its subsidiaries)(collectively,”Athletico”). Please visit our website for a full listing of all Athletico locations.
Family members and others involved in your care
• Unless you object, we may disclose relevant health information to a family
member, relative or close friend who is involved in your care or in payment
of your care.
For example, we may share information with a family member to help you
understand your care, handle your bills, or schedule appointments.
Workers’ compensation
• We may disclose your 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. These
programs provide benefits for work-related injuries or illnesses.
As required by law
• We may disclose health information about you when required by
federal, state or local law.
Health oversight activities
• We may use or disclose health information about you with health
oversight agencies for activities authorized by law.
For example, oversight activities may include audits, investigations
and inspections necessary for the government to monitor the health
care system.
Marketing communications
• We may use and disclose your health information to contact you with
information about treatment services, products or new locations that we
believe might be of interest to you.
Research
• We may use your health information for research purposes in certain
circumstances with your authorization.
Public health and safety issues
• We may share your health information for certain situations such as,
preventing disease, reporting suspected abuse, neglect, or domestic violence,
preventing or reducing a serious threat to anyone’s health or safety.
Law enforcement and specialized government functions
• We may disclose your health information for law enforcement purposes
as permitted by law. Under certain circumstances, we may disclose
health information to units of the government with specialized functions
such as the U.S. Military in response to requests as authorized by law.
Respond to lawsuits and legal actions
• We may share health information about you in response to a court or
administrative order, or in response to a subpoena or similar legal request.
To business associates
• We may disclose your health information to our “business associates” -
individuals or companies that provide services for Athletico.
For example, a business associate would include the company that
administers the billing claims for Athletico. In all cases, we require business
associates to appropriately safeguard the privacy of your information.
To Parents and legal guardians of minors
• As permitted by federal and state law, we may disclose health
information about minors to their parents or guardians.
Highly confidential information
• Federal and state laws provide additional privacy protection for certain
confidential health information. This includes information dealing with
mental health, HIV/AIDS, alcohol and drug abuse treatment.
Our Uses and Disclosures cont’d:
Uses and disclosures pursuant to an authorization
Other uses and disclosures of your protected health information, not described above, will be made only with your written authorization. You may revoke
your authorization, in writing, at any time, except that a revocation will not affect any uses or disclosures we have made in reliance on such authorization.
Changes to the terms of this notice
We can change the terms of this Notice and the changes will apply to all information we have about you. The new Notice will be available upon
request, posted at each of our facilities and our web site at athletico.com.
If you have any questions, or would like to discuss this Notice in more detail, please contact the privacy officer at 630-575-1962 or
compliance@athletico.com. This Notice is effective as of April 1, 2018.
This Notice of Privacy Practices applies to Athletico Holdings, LLC and its subsidiaries and controlled affiliates (including, without limitation, Athletico,
Ltd. and its subsidiaries)(collectively,”Athletico”). Please visit our website for a full listing of all Athletico locations.
Family members and others involved in your care
• Unless you object, we may disclose relevant health information to a family
member, relative or close friend who is involved in your care or in payment
of your care.
For example, we may share information with a family member to help you
understand your care, handle your bills, or schedule appointments.
Workers’ compensation
• We may disclose your 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. These
programs provide benefits for work-related injuries or illnesses.
As required by law
• We may disclose health information about you when required by
federal, state or local law.
Health oversight activities
• We may use or disclose health information about you with health
oversight agencies for activities authorized by law.
For example, oversight activities may include audits, investigations
and inspections necessary for the government to monitor the health
care system.
Marketing communications
• We may use and disclose your health information to contact you with
information about treatment services, products or new locations that we
believe might be of interest to you.
Research
• We may use your health information for research purposes in certain
circumstances with your authorization.
Public health and safety issues
• We may share your health information for certain situations such as,
preventing disease, reporting suspected abuse, neglect, or domestic violence,
preventing or reducing a serious threat to anyone’s health or safety.
Law enforcement and specialized government functions
• We may disclose your health information for law enforcement purposes
as permitted by law. Under certain circumstances, we may disclose
health information to units of the government with specialized functions
such as the U.S. Military in response to requests as authorized by law.
Respond to lawsuits and legal actions
• We may share health information about you in response to a court or
administrative order, or in response to a subpoena or similar legal request.
To business associates
• We may disclose your health information to our “business associates” -
individuals or companies that provide services for Athletico.
For example, a business associate would include the company that
administers the billing claims for Athletico. In all cases, we require business
associates to appropriately safeguard the privacy of your information.
To Parents and legal guardians of minors
• As permitted by federal and state law, we may disclose health
information about minors to their parents or guardians.
Highly confidential information
• Federal and state laws provide additional privacy protection for certain
confidential health information. This includes information dealing with
mental health, HIV/AIDS, alcohol and drug abuse treatment.
Our Uses and Disclosures cont’d:
Uses and disclosures pursuant to an authorization
Other uses and disclosures of your protected health information, not described above, will be made only with your written authorization. You may revoke
your authorization, in writing, at any time, except that a revocation will not affect any uses or disclosures we have made in reliance on such authorization.
Changes to the terms of this notice
We can change the terms of this Notice and the changes will apply to all information we have about you. The new Notice will be available upon
request, posted at each of our facilities and our web site at athletico.com.
If you have any questions, or would like to discuss this Notice in more detail, please contact the privacy officer at 630-575-1962 or
compliance@athletico.com. This Notice is effective as of April 1, 2018
..
This Notice of Privacy Practices applies to Athletico Holdings, LLC and its subsidiaries and controlled affiliates (including, without limitation, Athletico,
Ltd. and its subsidiaries)(collectively,”Athletico”). Please visit our website for a full listing of all Athletico locations.
Family members and others involved in your care
• Unless you object, we may disclose relevant health information to a family
member, relative or close friend who is involved in your care or in payment
of your care.
For example, we may share information with a family member to help you
understand your care, handle your bills, or schedule appointments.
Workers’ compensation
• We may disclose your 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. These
programs provide benefits for work-related injuries or illnesses.
As required by law
• We may disclose health information about you when required by
federal, state or local law.
Health oversight activities
• We may use or disclose health information about you with health
oversight agencies for activities authorized by law.
For example, oversight activities may include audits, investigations
and inspections necessary for the government to monitor the health
care system.
Marketing communications
• We may use and disclose your health information to contact you with
information about treatment services, products or new locations that we
believe might be of interest to you.
Research
• We may use your health information for research purposes in certain
circumstances with your authorization.
Public health and safety issues
• We may share your health information for certain situations such as,
preventing disease, reporting suspected abuse, neglect, or domestic violence,
preventing or reducing a serious threat to anyone’s health or safety.
Law enforcement and specialized government functions
• We may disclose your health information for law enforcement purposes
as permitted by law. Under certain circumstances, we may disclose
health information to units of the government with specialized functions
such as the U.S. Military in response to requests as authorized by law.
Respond to lawsuits and legal actions
• We may share health information about you in response to a court or
administrative order, or in response to a subpoena or similar legal request.
To business associates
• We may disclose your health information to our “business associates” -
individuals or companies that provide services for Athletico.
For example, a business associate would include the company that
administers the billing claims for Athletico. In all cases, we require business
associates to appropriately safeguard the privacy of your information.
To Parents and legal guardians of minors
• As permitted by federal and state law, we may disclose health
information about minors to their parents or guardians.
Highly confidential information
• Federal and state laws provide additional privacy protection for certain
confidential health information. This includes information dealing with
mental health, HIV/AIDS, alcohol and drug abuse treatment.
Our Uses and Disclosures cont’d:
Uses and disclosures pursuant to an authorization
Other uses and disclosures of your protected health information, not described above, will be made only with your written authorization. You may revoke
your authorization, in writing, at any time, except that a revocation will not affect any uses or disclosures we have made in reliance on such authorization.
Changes to the terms of this notice
We can change the terms of this Notice and the changes will apply to all information we have about you. The new Notice will be available upon
request, posted at each of our facilities and our web site at athletico.com.
If you have any questions, or would like to discuss this Notice in more detail, please contact the privacy officer at 630-575-1962 or
compliance@athletico.com. This Notice is effective as of April 1, 2018.
This Notice of Privacy Practices applies to Athletico Holdings, LLC and its subsidiaries and controlled affiliates (including, without limitation, Athletico,
Ltd. and its subsidiaries)(collectively,”Athletico”). Please visit our website for a full listing of all Athletico locations.
Family members and others involved in your care
• Unless you object, we may disclose relevant health information to a family
member, relative or close friend who is involved in your care or in payment
of your care.
For example, we may share information with a family member to help you
understand your care, handle your bills, or schedule appointments.
Workers’ compensation
• We may disclose your 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. These
programs provide benefits for work-related injuries or illnesses.
As required by law
• We may disclose health information about you when required by
federal, state or local law.
Health oversight activities
• We may use or disclose health information about you with health
oversight agencies for activities authorized by law.
For example, oversight activities may include audits, investigations
and inspections necessary for the government to monitor the health
care system.
Marketing communications
• We may use and disclose your health information to contact you with
information about treatment services, products or new locations that we
believe might be of interest to you.
Research
• We may use your health information for research purposes in certain
circumstances with your authorization.
Public health and safety issues
• We may share your health information for certain situations such as,
preventing disease, reporting suspected abuse, neglect, or domestic violence,
preventing or reducing a serious threat to anyone’s health or safety.
Law enforcement and specialized government functions
• We may disclose your health information for law enforcement purposes
as permitted by law. Under certain circumstances, we may disclose
health information to units of the government with specialized functions
such as the U.S. Military in response to requests as authorized by law.
Respond to lawsuits and legal actions
• We may share health information about you in response to a court or
administrative order, or in response to a subpoena or similar legal request.
To business associates
• We may disclose your health information to our “business associates” -
individuals or companies that provide services for Athletico.
For example, a business associate would include the company that
administers the billing claims for Athletico. In all cases, we require business
associates to appropriately safeguard the privacy of your information.
To Parents and legal guardians of minors
• As permitted by federal and state law, we may disclose health
information about minors to their parents or guardians.
Highly confidential information
• Federal and state laws provide additional privacy protection for certain
confidential health information. This includes information dealing with
mental health, HIV/AIDS, alcohol and drug abuse treatment.
Our Uses and Disclosures cont’d:
Uses and disclosures pursuant to an authorization
Other uses and disclosures of your protected health information, not described above, will be made only with your written authorization. You may revoke
your authorization, in writing, at any time, except that a revocation will not affect any uses or disclosures we have made in reliance on such authorization.
Changes to the terms of this notice
We can change the terms of this Notice and the changes will apply to all information we have about you. The new Notice will be available upon
request, posted at each of our facilities and our web site at athletico.com.
If you have any questions, or would like to discuss this Notice in more detail, please contact the privacy officer at 630-575-1962 or
compliance@athletico.com. This Notice is effective as of April 1, 2018.
This Notice of Privacy Practices applies to Athletico Holdings, LLC and its subsidiaries and controlled affiliates (including, without limitation, Athletico,
Ltd. and its subsidiaries)(collectively,”Athletico”). Please visit our website for a full listing of all Athletico locations.
Family members and others involved in your care
• Unless you object, we may disclose relevant health information to a family
member, relative or close friend who is involved in your care or in payment
of your care.
For example, we may share information with a family member to help you
understand your care, handle your bills, or schedule appointments.
Workers’ compensation
• We may disclose your 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. These
programs provide benefits for work-related injuries or illnesses.
As required by law
• We may disclose health information about you when required by
federal, state or local law.
Health oversight activities
• We may use or disclose health information about you with health
oversight agencies for activities authorized by law.
For example, oversight activities may include audits, investigations
and inspections necessary for the government to monitor the health
care system.
Marketing communications
• We may use and disclose your health information to contact you with
information about treatment services, products or new locations that we
believe might be of interest to you.
Research
• We may use your health information for research purposes in certain
circumstances with your authorization.
Public health and safety issues
• We may share your health information for certain situations such as,
preventing disease, reporting suspected abuse, neglect, or domestic violence,
preventing or reducing a serious threat to anyone’s health or safety.
Law enforcement and specialized government functions
• We may disclose your health information for law enforcement purposes
as permitted by law. Under certain circumstances, we may disclose
health information to units of the government with specialized functions
such as the U.S. Military in response to requests as authorized by law.
Respond to lawsuits and legal actions
• We may share health information about you in response to a court or
administrative order, or in response to a subpoena or similar legal request.
To business associates
• We may disclose your health information to our “business associates” -
individuals or companies that provide services for Athletico.
For example, a business associate would include the company that
administers the billing claims for Athletico. In all cases, we require business
associates to appropriately safeguard the privacy of your information.
To Parents and legal guardians of minors
• As permitted by federal and state law, we may disclose health
information about minors to their parents or guardians.
Highly confidential information
• Federal and state laws provide additional privacy protection for certain
confidential health information. This includes information dealing with
mental health, HIV/AIDS, alcohol and drug abuse treatment.
Our Uses and Disclosures cont’d:
Uses and disclosures pursuant to an authorization
Other uses and disclosures of your protected health information, not described above, will be made only with your written authorization. You may revoke
your authorization, in writing, at any time, except that a revocation will not affect any uses or disclosures we have made in reliance on such authorization.
Changes to the terms of this notice
We can change the terms of this Notice and the changes will apply to all information we have about you. The new Notice will be available upon
request, posted at each of our facilities and our web site at athletico.com.
If you have any questions, or would like to discuss this Notice in more detail, please contact the privacy officer at 630-575-1962 or
compliance@athletico.com. This Notice is effective as of April 1, 2018.
This Notice of Privacy Practices applies to Athletico Holdings, LLC and its subsidiaries and controlled affiliates (including, without limitation, Athletico,
Ltd. and its subsidiaries)(collectively,”Athletico”). Please visit our website for a full listing of all Athletico locations.
Family members and others involved in your care
• Unless you object, we may disclose relevant health information to a family
member, relative or close friend who is involved in your care or in payment
of your care.
For example, we may share information with a family member to help you
understand your care, handle your bills, or schedule appointments.
Workers’ compensation
• We may disclose your 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. These
programs provide benefits for work-related injuries or illnesses.
As required by law
• We may disclose health information about you when required by
federal, state or local law.
Health oversight activities
• We may use or disclose health information about you with health
oversight agencies for activities authorized by law.
For example, oversight activities may include audits, investigations
and inspections necessary for the government to monitor the health
care system.
Marketing communications
• We may use and disclose your health information to contact you with
information about treatment services, products or new locations that we
believe might be of interest to you.
Research
• We may use your health information for research purposes in certain
circumstances with your authorization.
Public health and safety issues
• We may share your health information for certain situations such as,
preventing disease, reporting suspected abuse, neglect, or domestic violence,
preventing or reducing a serious threat to anyone’s health or safety.
Law enforcement and specialized government functions
• We may disclose your health information for law enforcement purposes
as permitted by law. Under certain circumstances, we may disclose
health information to units of the government with specialized functions
such as the U.S. Military in response to requests as authorized by law.
Respond to lawsuits and legal actions
• We may share health information about you in response to a court or
administrative order, or in response to a subpoena or similar legal request.
To business associates
• We may disclose your health information to our “business associates” -
individuals or companies that provide services for Athletico.
For example, a business associate would include the company that
administers the billing claims for Athletico. In all cases, we require business
associates to appropriately safeguard the privacy of your information.
To Parents and legal guardians of minors
• As permitted by federal and state law, we may disclose health
information about minors to their parents or guardians.
Highly confidential information
• Federal and state laws provide additional privacy protection for certain
confidential health information. This includes information dealing with
mental health, HIV/AIDS, alcohol and drug abuse treatment.
Our Uses and Disclosures cont’d:
Uses and disclosures pursuant to an authorization
Other uses and disclosures of your protected health information, not described above, will be made only with your written authorization. You may revoke
your authorization, in writing, at any time, except that a revocation will not affect any uses or disclosures we have made in reliance on such authorization.
Changes to the terms of this notice
We can change the terms of this Notice and the changes will apply to all information we have about you. The new Notice will be available upon
request, posted at each of our facilities and our web site at athletico.com.
If you have any questions, or would like to discuss this Notice in more detail, please contact the privacy officer at 630-575-1962 or
compliance@athletico.com. This Notice is effective as of April 1, 2018.
This Notice of Privacy Practices applies to Athletico Holdings, LLC and its subsidiaries and controlled affiliates (including, without limitation, Athletico,
Ltd. and its subsidiaries)(collectively,”Athletico”). Please visit our website for a full listing of all Athletico locations.
Family members and others involved in your care
• Unless you object, we may disclose relevant health information to a family
member, relative or close friend who is involved in your care or in payment
of your care.
For example, we may share information with a family member to help you
understand your care, handle your bills, or schedule appointments.
Workers’ compensation
• We may disclose your 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. These
programs provide benefits for work-related injuries or illnesses.
As required by law
• We may disclose health information about you when required by
federal, state or local law.
Health oversight activities
• We may use or disclose health information about you with health
oversight agencies for activities authorized by law.
For example, oversight activities may include audits, investigations
and inspections necessary for the government to monitor the health
care system.
Marketing communications
• We may use and disclose your health information to contact you with
information about treatment services, products or new locations that we
believe might be of interest to you.
Research
• We may use your health information for research purposes in certain
circumstances with your authorization.
Public health and safety issues
• We may share your health information for certain situations such as,
preventing disease, reporting suspected abuse, neglect, or domestic violence,
preventing or reducing a serious threat to anyone’s health or safety.
Law enforcement and specialized government functions
• We may disclose your health information for law enforcement purposes
as permitted by law. Under certain circumstances, we may disclose
health information to units of the government with specialized functions
such as the U.S. Military in response to requests as authorized by law.
Respond to lawsuits and legal actions
• We may share health information about you in response to a court or
administrative order, or in response to a subpoena or similar legal request.
To business associates
• We may disclose your health information to our “business associates” -
individuals or companies that provide services for Athletico.
For example, a business associate would include the company that
administers the billing claims for Athletico. In all cases, we require business
associates to appropriately safeguard the privacy of your information.
To Parents and legal guardians of minors
• As permitted by federal and state law, we may disclose health
information about minors to their parents or guardians.
Highly confidential information
• Federal and state laws provide additional privacy protection for certain
confidential health information. This includes information dealing with
mental health, HIV/AIDS, alcohol and drug abuse treatment.
Our Uses and Disclosures cont’d:
Uses and disclosures pursuant to an authorization
Other uses and disclosures of your protected health information, not described above, will be made only with your written authorization. You may revoke
your authorization, in writing, at any time, except that a revocation will not affect any uses or disclosures we have made in reliance on such authorization.
Changes to the terms of this notice
We can change the terms of this Notice and the changes will apply to all information we have about you. The new Notice will be available upon
request, posted at each of our facilities and our web site at athletico.com.
If you have any questions, or would like to discuss this Notice in more detail, please contact the privacy officer at 630-575-1962 or
compliance@athletico.com. This Notice is effective as of April 1, 2018.
This Notice of Privacy Practices applies to Athletico Holdings, LLC and its subsidiaries and controlled affiliates (including, without limitation, Athletico,
Ltd. and its subsidiaries)(collectively,”Athletico”). Please visit our website for a full listing of all Athletico locations.
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