THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATON. PLEASE REVIEW IT CAREFULLY.
1) Uses and Disclosures Anna Kotula, DPT will use your protected health information (PHI) for the purposes of treatment, payment and health care operations.
Treatment includes the disclosure of health information to other providers who have referred you for services or are involved in your care. This may include doctors, nurses, technicians and other physical therapists. For example, I may assess that a patient being treated by me with a medical diagnosis of “low back pain” may benefit from further evaluation by his/ her medical doctor. The health information I share with the patient’s physician would be considered a treatment related disclosure.
Payment includes the disclosure of health information to your insurance company, including Medicare and Medicaid, so payment can be obtained for services rendered. Your insurance company may request to review your medical record to determine that your care was necessary.
Health Care Operations includes the utilization of your records to monitor the quality of care being given by me or for business planning activities.
Other Special Uses
My practice may use your PHI to send you an appointment reminder, to email a home exercise program, and to inform you of other appropriate health-related services.
Uses and disclosures required by law
The federal health information privacy regulations either permit or require me to use or disclose your PHI in the following ways: we may share some of your PHI with a family member or a friend involved in your care if you do not object, I may use your PHI in an emergency situation when you may not be able to express yourself, and I may use or disclose your PHI for research purposes if I am provided with very specific assurances that your privacy will be protected. I may also disclose your PHI when I am required to do so by law, for example by a court order or subpoena. Disclosures to health oversight agencies are sometimes required by law to report certain diseases or adverse drug reactions. I may use and disclose health information to you to avert a serious health threat to your health or safety of the public or others. If you are in the Armed Forces, I may release information about you when it is determined to be necessary by the appropriate military command authorities. I may release information about you for workers’ compensation or other similar programs that provide benefits for work-related injury or illness.
Your authorization is required before your PHI maybe disclosed by me for other purposes.
2) Your Privacy Rights
Restrictions
You have the right to request restrictions on how your PHI is used; however, although I will do my best to accommodate your needs, I am not required to agree with your request. If I do agree, I am required and will be glad to abide by your request.
Confidential Communications
You have the right to request your confidential information from me at a location of your choosing. This request must be in writing.
Access to PHI
You have the right to request a copy of your medical record. This request must be in writing and I may charge a fee to cover only the costs of copying and mailing.
Amendments
You have the right to request an amendment of your PHI, if you disagree with what it says about you. This request must be made in writing. If I disagree with you, I am not required to make the change. You have the right to submit a written statement about why you disagree that will become apart of your record. It is of utmost importance to me that you feel accurately represented. I may not amend parts of your medical record that I did not create.
Accounting of Disclosures
You have the right to request an accounting of any disclosures made in the previous six years. These disclosures will not include those made for treatment, payment, or health car operations or for which I have obtained authorization.
Concerns or Complaints
If you feel that your privacy rights have been violated, you have the right to make a complaint to me in writing without fear of retaliation. Your complaint should contain enough specific information so that I may adequately investigate and respond to your concerns. If you are not satisfied with my response, you may also communicate directly to the Secretary of Health and Human Services.
My Duty to Protect Your Privacy
I am required to comply with the federal health information privacy regulations by maintaining the privacy of your PHI. These rules require me to provide you with this document, my Notice of Privacy Practices. I reserve the right to update this notice if required by law. If I do update this at any time in the future, you will receive a revised notice when next you seek treatment from me.
Anna Kotula, DPT
Ojai Valley Athletic Club
409 S. Fox Street
Ojai, CA 93023
805.646.5683 ext 15
805.798.1408 cell
805.640.8325 fax
kotuladpt@yahoo.com
If you would like more information about my privacy practices or to file a complaint, please feel free to contact me by phone, email or standard mail.