East Valley 480-892-9777

West Valley 623-334-5299



NOTICE OF PRIVACY PRACTICES

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.

Horizon Pediatric Therapy, Inc. (“Horizon”) is committed to protecting the confidentiality of its patients’ health information.  We are required by law to maintain the privacy of your health information and to provide you with notice of our legal duties and privacy practices related to your health information. This Notice of Privacy Practices describes how we may use and disclose your health information and your rights concerning your information. 

USES AND DISCLOSURES WITHOUT YOUR AUTHORIZATION

Your authorization is not required for us to use or disclose your health information for the following purposes:

Treatment:  We will use and disclose your health information to provide, coordinate and/or manage your treatment and any related services.  For example, a physical therapist at Horizon will be allowed to have access to your health information to assist in your treatment at Horizon and for follow-up care.  We can also share your health information with physicians, nurses, technicians and other providers involved in your care.  

Payment:  Your health information will be used or disclosed, as needed, to obtain payment for the health care items and services we deliver to you.  For example, your health plan or health insurance company may ask to see parts of your health information before they will pay us for your treatment.

Healthcare Operations:  We may use or disclose your health information in order to carry out our general business activities or the business activities of other providers involved in your care under certain circumstances.  These activities include, but are not limited to, training and education; quality assessment/ improvement activities; risk management; claims management; legal consultation; therapist and employee/staff review activities; and other business planning activities. 

Appointments and Health-Related Services:  We may use your health information to contact you about an upcoming appointment, to inform you about possible treatment options or alternatives, or to tell you about other health-related services available to you.

Family and Friends:  We may disclose your health information to a family member or friend who is involved in your care or to someone who helps pay for your care.  If you do not want us to disclose your health information to family members or others involved in your care, you may contact our Privacy Officer.  Contact information for our Privacy Officer is set forth below.  We may also use or disclose your medical information to notify (or assist in notifying) a family member, legally authorized representative or other person responsible for your care of your location and general condition. 

Business Associates:  We enter into contracts with third-parties known as business associates.  These business associates provide services to us or perform functions on our behalf, e.g., accountants, consultants and attorneys. We may disclose your health information to our business associates once they have agreed in writing to safeguard your health information.  Business associates are also required by law to protect the privacy of your health information.   

Required By Law:  We may use or disclose your health information to the extent the use or disclosure is required by law.  Any such use or disclosure will be limited to what is required under the law.     

Public Health Activities:  We may use your health information for public health activities such as reporting deaths, communicable diseases, injuries, or disabilities; ensuring the safety of drugs and medical devices; and for work place surveillance or work-related illness or injury.

Health Oversight Activities:  We may disclose your health information to a health oversight agency for activities such as audits; civil, administrative or criminal investigations, proceedings or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight as authorized by law.

Food and Drug Administration (FDA):  We may disclose your medical information to a person or company subject to the FDA to report adverse events, product defects or problems or biologic product deviations; to track FDA-regulated products; to enable product recalls; to make repairs or replacements; to conduct post-marketing surveillance information or for other purposes related to the quality, safety or effectiveness of a product or activity regulated by the FDA.

Law Enforcement:  We may disclose your medical information to law enforcement in limited circumstances, such as to identify or locate suspects, fugitives, witnesses or victims of a crime, to report deaths from a crime, to report crime on our premises or in emergency treatment situations.

Judicial and Administrative Proceedings:  We may disclose information about you in response to an order of a court or administrative tribunal as expressly authorized by such order.  We may also disclose information about you in response to a subpoena, discovery request or other lawful process not accompanied by an order of a court or administrative tribunal, under certain circumstances as permitted by law.

To Avert a Serious Threat to Health or Safety: We may use or disclose your health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.  We may also disclose information about you if it is necessary for law enforcement authorities to identify or apprehend an individual.

Disaster Relief Efforts:  We may use or disclose your health information to an authorized public or private entity to assist in disaster relief efforts.  You may have the opportunity to object unless it would impede our ability to respond to emergency circumstances.     

Coroners, Medical Examiners and Funeral Directors:  We may disclose health information consistent with applicable law to coroners, medical examiners and funeral directors to assist them in carrying out their duties.

Organ and Tissue Donation:  We may disclose health information consistent with applicable law to organizations that handle organ, eye or tissue donation or transplantation.

Research:  Under certain circumstances, we may also use and disclose information about you for research purposes.  All research projects are subject to a special approval process through an appropriate committee. 

Fundraising:  We may use certain information to contact you as part of our fundraising efforts.  If you receive such a communication from us, you will be provided an opportunity to opt-out of receiving such communications in the future.

Workers’ Compensation:  We may disclose your health information as authorized to comply with workers’ compensation laws and other similar programs established by law.

Military, Veterans, National Security and Other Government Purposes:  If you are a member of the armed forces, we may release your health information as required by military command authorities or to the Department of Veterans Affairs.  We may also disclose medical information to authorized federal officials for intelligence and national security purposes.

Correctional Institutions: If you are or become an inmate of a correctional institution or are in the custody of a law enforcement official, we may disclose to the institution or law enforcement official information necessary for the provision of health services to you, your health and safety, the health and safety of other individuals and law enforcement on the premises of the institution and the administration and maintenance of the safety, security and good order of the institution.

Victims of Abuse, Neglect or Domestic Violence:  We may disclose your health information to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect or domestic violence.  

OTHER USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION

If we wish to use or disclose your health information for a purpose not discussed in this Notice, we will seek your authorization.  Specific examples of uses and disclosures of health information requiring your authorization include: (i) most uses and disclosures of psychotherapy notes (private notes of a mental health professional kept separately from a medical record); (ii) most uses and disclosures of your health information for marketing purposes; and (iii) disclosures of your health information that constitute the sale of your health information. 

Additionally, certain categories of health information have additional protection under state or other federal laws that are more stringent than HIPAA.  For those types of information, we are often required to get your permission before disclosing it to a third-party.

If we are required to obtain your authorization to use or disclose your health information, you may revoke your authorization at any time in writing, except to the extent that we have acted in reliance on your authorization. 

YOUR HEALTH INFORMATION RIGHTS

Although your health information is our property, you have the right to: 

Inspect and/or obtain a copy of your health information.  You have the right to inspect and/or obtain a copy of your health information maintained in a designated record set.  If we maintain your health information electronically, you may obtain an electronic copy of the information or ask us to send it to a person or organization that you identify.  To request to inspect and/or obtain a copy of your health information, you must submit a written request to our Privacy Officer.  If you request a copy (paper or electronic) of your health information, we may charge you a reasonable, cost-based fee.    

Request a restriction on certain uses and disclosures of your health information.  You have the right to ask us not to use or disclose any part of your health information for purposes of treatment, payment or healthcare operations. 

While we will consider your request, we are only required to agree to restrict a disclosure to a health plan for purposes of payment or healthcare operations (but not for treatment) if the information applies solely to a healthcare item or service for which we have been paid out of pocket in full.  If we do agree to a restriction, we will not use or disclose your health information in violation of that restriction unless it is needed to provide emergency treatment. 

To request a restriction, you must submit a written request to our Privacy Officer.  We will not agree to restrictions on health information uses or disclosures that are legally required or necessary to administer our business.

Request confidential communications.  You have the right to request that we communicate with you about your health information in a certain way or at a certain location.  For example, you can ask that we only contact you at work or by mail.  To request confidential communication of your health information, you must submit a written request to our Privacy Officer stating how or when you would like to be contacted.  We will accommodate all reasonable requests.  We will not require you to provide an explanation for your request.   

Request an amendment to your health information.  If you believe that any information in your patient record is incorrect, or if you believe important information is missing, you may request that we correct the existing information or add the missing information.  To request such an amendment, you must submit a written request to our Privacy Officer. 

Request an accounting of certain disclosures.  You have the right to receive an accounting of certain disclosures we have made of your health information. To request an accounting, you must submit a written request to our Privacy Officer.  The first accounting you request within a 12 month period will be provided free of charge.  We may charge you for any additional requests in that same 12 month period.

Obtain a paper copy of this Notice.  You have the right to obtain a paper copy of this Notice upon request, even if you agreed to accept this Notice electronically.  To obtain a paper copy of this Notice, contact our Privacy Officer. 

OUR RESPONSIBILITIES

We are required to (i) maintain the privacy of your health information as required by law; (ii) provide you with notice of our legal duties and privacy practices with respect to your health information; (iii) abide by the terms of such notice; and (iv) notify you following a breach of your health information that is not secured in accordance with certain security standards. 

We reserve the right to change the terms of this Notice and to make the provisions of the new Notice effective for all health information that we maintain.  If we change the terms of this Notice, the revised Notice will be made available upon request, posted to our website and posted at our delivery sites.  Copies of the current Notice may be obtained by contacting our Privacy Officer or by visiting our website at: http://horizonaz.com/index.php.

QUESTIONS, CONCERNS OR COMPLAINTS

If you have any questions or want more information about this Notice or how to exercise your health information rights, you may contact our Privacy Officer by telephone: (480) 892-9777, by mail: Lisa Fasano, Horizon Pediatric Therapy, Inc., 551 S. Higley Road, Mesa, AZ 85206 or by e-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it. .

If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer (at the address listed above) or with the Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Ave. S.W., Room 509F HHH Bldg., Washington DC 20201 ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it. ).  We will not retaliate against you for filing a complaint. 

The effective date of this notice is September 3, 2015.

Signature below is acknowledgment that you have read and understand this Notice. 

Patient Name:           DOB:      


Signature:           Date: