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Health Information Privacy Notice


  1. About Protected Health Information “PHI”

In this notice, “we” or “us” refer to Physical Achievement Center, LLC, and our workforce of employees and volunteers.  “You” or “your” refers to each of our patients who are entitled a copy of this notice.  We will use good faith regarding protecting your privacy, however, it is no guarantee from any and all potential risks. 

We are required by federal and state law to protect the privacy of your health information.  For example, federal health information privacy regulations require us to protect health information about you in a manner that we describe here.  Certain types of health information may specifically identify you.  Because we must protect this health information, we refer to it as “Protected Health Information” or “PHI”.  In this notice we will tell you about:

  • How we will use your PHI
  • When we may disclose your PHI to others
  • Your privacy rights and how to use them
  • Our privacy duties
  • Who to contact for more information or a complaint

2.  Some ways we use or disclose your Protected Health Information

We will use your PHI to treat you.  We will use your PHI and disclose it in order for us to get paid for your care.  We are allowed to dispense or disclose your PHI for certain activities that we call “health care operations”.  Health care operations involve the administration and quality assurance activities in our facility.  We will give you examples of each of these to help explain them.  However, this is NOT a complete list of all uses or disclosures. 

We use and disclose your PHI in your course of treatment.  For example, if you are in our clinic and one of our employees has a question about your condition, we may communicate with your treating physician regarding your diagnosis and plan of care so that we can provide the optimal course of treatment for you.  We may also disclose your PHI for other related types of treatment activities. It may be necessary for us to communicate with your referring physician regarding your evaluation and progress in therapy.  This may include an introductory letter from our clinic informing the physician of your injury/injuries, as well as who your therapist is in case the physician needs to contact them.  This may also include evaluations, progress notes, etc.  This allows us to keep a line of communication with your physician about your progress and plan of care.

We may contact you to provide you appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

After we treat you, we will ask your insurer to pay us.  We use a billing company to administer our billing for us.  We provide our billing company your medical information so that they can provide the required information to your insurance company.  We, or our billing company, might input some information into our computers to send a claim to your insurance company.  In this instance, we or our billing company, tell your insurer what type of health problem you had and what we did to treat you.  Your insurer may ask us to give them your claim or subscriber number or your insurer may want to review your medical records to be sure your care was necessary.

Special Uses:
We may also use or disclose your PHI for the purposes that involve your relationship to us as a patient.  We may use or disclose your PHI to:

  • Remind you that you have an appointment with us for treatment
  • To contact you regarding your patient account.

Your Authorization May be Required:
In many cases summarized here, we may use or disclose your PHI either with your consent or as required or permitted by law.  In all other cases we must ask for, and you must agree to give, a written authorization that has specific instructions and/or limits on our disclosure of your PHI.  If you later change your mind, you may revoke your authorization.

  1. Certain Uses and Disclosures of your PHI that are Required or Permitted by Law.

Many laws and regulations apply to us that affect your PHI.  These laws and regulations may either require us or permit us to use or disclose your PHI.  From the federal health information privacy regulations, here is a list describing required or permitted uses and disclosures. 

  • If you do not verbally object, we may share some of your PHI with a family member or friend who is involved in your care
  • We may use your PHI in an emergency when you are not able to express yourself.
  • When required by law: for example, when a subpoena is ordered by a court to turn over certain types of your PHI, we must do so.
  • For public health activities such as reporting a communicable disease or reporting an adverse drug reaction to the Food and Drug Administration (FDA).
  • To report abuse, neglect, or domestic violence, as required by law.
  • To government regulators or its agents to determine whether we comply with all applicable rules and regulations.
  • When properly requested by law enforcement, or for other legal requirements.
  • If we believe that disclosing your PHI will avert a potential health hazard or threat to public safety, such as an imminent crime against another person.
  • If you are in the armed forces, and it is deemed necessary by appropriate military personnel
  • If your workers’ compensation claims carrier requires various PHI information.
  1. Certain Requirements We must Follow:

Several state laws may apply to your PHI that set stricter standards then the protections required by federal health privacy regulations.

  1. Your Privacy Rights and How to Exercise Them.

You have specific rights under the federally required privacy program, these are summarized here.

Your Right to Request Limited Use or Disclosure 
You have the right to request that we do not use or disclose your PHI in a particular way.  However, we are NOT required to abide by your request.  If we do agree with your request, we must abide by the agreement

Your Right to Confidential Communication
You have the right to receive confidential communication from us at the location you provide.  We require that you make your request in writing, providing us with the other address and explain to us if the request will interfere with your care.

Your Right to Revoke Your Consent or Authorization
If you have granted us your consent or authorization to use or disclose your PHI, you may revoke the consent or authorization in writing.  However, if we have relied on your consent or authorization we may use or disclose your PHI to that extent.

Your Right to Inspect and Copy
You have the right to inspect and copy your PHI.  We may refuse to give you access to your PHI if we think it may cause harm, but we must explain why and provide you with someone to contact about our decision who will explain how and when to get a review of our refusal.

Your Rights to Amend Your PHI
If you disagree with what your PHI in our records say about you, you have the right to request in writing that we amend your PHI, when it is in a record that we have created or maintained for our purposes.  We are not required to respond to your request if the records in question are not our records.  You then have the right to submit a written statement as to why you disagree.  We may then prepare a counterstatement, both of which will become a part of our record about you. 

Your right to Know Who Else Sees Your PHI
You have the right to request an accounting of certain disclosures that we have made of your PHI over the past six years.  We do not have to account for all disclosures including those pertaining to treatment, payment, and health care operations as described above.  There is no charge for an annual accounting, but there may be a charge for additional accounting.  You have the right to withdraw that request at any time.

Your rights To Complain
If you believe your privacy rights have been violated, you have the right to make a complaint to us, or to the Secretary of Health and Human Services.  We will not retaliate against you if you make a complaint against us.  To file a complaint, you must submit it in writing to the contact listed in section 7. below.  You should provide us with a reasonable amount of detail to enable us to perform a proper investigation.

  1. Some of Our Privacy Obligations and How We Perform Them.

We are required to comply with the federal health information privacy regulations.  These rules require us to protect your PHI.  These rules require us to give you notice of our privacy practices.  This document is our notice.  If you did not get a paper copy of this notice, you may have one.  We will abide by the privacy practices set fourth in this notice.  However, we reserve the right to change this notice or our privacy practices as permitted by law.  If we change out notice of privacy practices, we will provide a revised notice when you next receive treatment from us. 

  1. Contact Information

Eric Koehler
Physical Achievement Center, LLC
2080 W 9th Avenue #303
Oshkosh WI, 54904

  1. Effective Date

This notice takes effect August 20, 2017