Fillable Your Information. Your Rights. Our Responsibilities.

Fill Online, Printable, Fillable, Blank Your Information. Your Rights. Our Responsibilities. Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Your Information. Your Rights. Our Responsibilities.

On average this form takes 2 minutes to complete

The Your Information. Your Rights. Our Responsibilities. form is 5 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 6 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement,
and other government requests
• Respond to lawsuits and legal actions
➤ See pages 3 and 4
for more information
on these uses and
disclosures
You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared
your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy
rights have been violated
➤ See page 2 for
more information on
these rights and how
to exercise them
Our
Uses and
Disclosures
Your
Rights
➤ See page 3 for
more information on
these choices and
how to exercise them
You have some choices in the way that we
use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
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.
Your Information.
Your Rights.
Our Responsibilities.
Your
Choices
Notice of Privacy Practices • Page 1
OSR Physical Therapy
Notice of Privacy Practices
Corporate Office
41125 N. Daisy Mountain Dr.
Anthem, AZ 85086
623.551.9706 www.osrphysicaltherapy.com
Notice of Privacy Practices • Page 2
When it comes to your health information, you have certain rights.
This section explains your rights and some of our responsibilities to help you.
Your
Rights
Get an electronic or
paper copy of your
medical record
• You can ask to see or get an electronic or paper copy of your medical record and
other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30
days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct
your medical record
• You can ask us to correct health information about you that you think is incorrect
or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential
communications
• You can ask us to contact you in a specific way (for example, home or office phone)
or to send mail to a different address.
• We will say “yes” to all reasonable requests.
Ask us to 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.
Get a list of those
with whom we’ve
shared information
• You can ask for a list (accounting) of the times we’ve shared your health information
for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and
health care operations, and certain other disclosures (such as any you asked us to
make). We’ll provide one accounting a year for free but will charge a reasonable,
cost-based fee if you ask for another one within 12 months.
Get 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.
Choose someone
to act for you
• If you have given someone medical power of attorney or if someone is your legal
guardian, that person can exercise your rights and make choices about your health
information.
• We will make sure the person has this authority and can act for you before we take
any action.
File a complaint if
you feel your rights
are violated
• You can complain if you feel we have violated your rights by contacting us using the
information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services
Ofce for Civil Rights by sending a letter to 200 Independence Avenue, S.W.,
Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/
privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
Notice of Privacy Practices • Page 3
In these cases, you have
both the right and choice
to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious,
we may go ahead and share your information if we believe it is in your best interest.
We may also share your information when needed to lessen a serious and imminent
threat to health or safety.
In these cases we never
share your information
unless you give us
written permission:
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to
contact you again.
For certain health information, you can tell us your choices about what
we share. If you have a clear preference for how we share your information in the
situations described below, talk to us. Tell us what you want us to do, and we will follow
your instructions.
Your
Choices
Treat you
• We can use your health information and
share it with other professionals who are
treating you.
Example: A doctor treating you for an
injury asks another doctor about your
overall health condition.
Run our
organization
• We can use and share your health
information to run our practice, improve
your care, and contact you when necessary.
Example: We use health information
about you to manage your treatment and
services.
Bill for your
services
• We can use and share your health
information to bill and get payment from
health plans or other entities.
Example: We give information about you
to your health insurance plan so it will pay
for your services.
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Our
Uses and
Disclosures
continued on next page
Notice of Privacy Practices • Page 4
Help with public health
and safety issues
• We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
Do research
• We can use or share your information for health research.
Comply with the law
• We will share information about you if state or federal laws require it,
including with the Department of Health and Human Services if it wants to
see that we’re complying with federal privacy law.
Respond to organ and
tissue donation requests
• We can share health information about you with organ procurement
organizations.
Work with a medical
examiner or funeral director
• We can share health information with a coroner, medical examiner, or funeral
director when an individual dies.
Address workers’
compensation, law
enforcement, and other
government requests
• We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and
presidential protective services
Respond to lawsuits and
legal actions
•
We can share health information about you in response to a court or
administrative order, or in response to a subpoena.
How else can we use or share your health information? We are allowed or required to share your
information in other ways – usually in ways that contribute to the public good, such as public health and research.
We have to meet many conditions in the law before we can share your information for these purposes. For more
information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Our practice does not create or maintain a hospital directory.
Our practice does not create or maintain psychotherapy notes.
Notice of Privacy Practices • Page 5
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security
of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in
writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you
change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
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, in our office, and on our web site.
This Notice of Privacy Practices applies to the following organizations.
The Effective Date of This Notice is September 20, 2013
Orthopedic and Sports Rehab Specialists at Anthem, LLC (OSR Physical Therapy)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Your Information. Your Rights. Our Responsibilities.

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document