As required by the HIPAA Privacy Rule, this Notice of Privacy Practices for Protected Health Information serves to inform you how Enhanced Performance Therapy may use and disclose your protected health information, your rights with respect to the information and how you may exercise these rights, including how you may complain about these uses and disclosures or get access to your Protected Health Information. Please review it carefully. If you have any questions about this Notice, please contact Kendal Jacobson.

Uses or Disclosures of Your Protected Health Information

Authorization and Consent: Except as outlined below, we will not use or disclose your personal health information for any purpose other than treatment, payment, or health care operations unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in writing unless we have taken any action in reliance on the authorization.

Uses and Disclosures for Treatment: With your agreement, we will make uses and disclosures of your personal health information as necessary for your treatment. Doctors, physical therapists, nurses and other professionals who have referred you for services or are involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to your course of treatment that may include procedures, medications, tests, medical history.

Uses and Disclosures for Payment: As Enhanced Performance Therapy does not accept payment from third parties, your protected health information will not be used or disclosed with insurance companies without your written request. You must fill out an Authorization to Disclose Health Information form and the records will be released by the method of your choice: fax, mail, or picked up.

Uses and Disclosures for Health Care Operations: With your agreement, we will use and disclose your protected health information as necessary, and as permitted by law, for our health care operations, which may include clinical improvement, professional peer review, business management, accreditation and licensing, quality assessment activities. We may use or disclose your protected health information, as necessary, to contact you to remind you of an appointment.

Individuals Involved in Your Care: With your written agreement, we may disclose your protected health information to designated family, friends, and others involved in your care in order to facilitate that person’s involvement. We may use your protected health information without your approval in an emergency situation when you may not be able to express yourself, and we determine that a limited disclosure to involved individuals may be in your best interest. We may also disclose limited personal health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.

Appointments and Services: We may contact you to provide appointment reminders or other health-related benefits and services that may be of interest to you. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your personal health information from us by alternative means or at an alternative location. For example, if you would prefer appointment reminders be emailed versus left on voicemail, we will accommodate reasonable requests. You also have the right to request that we not send you any future marketing materials. Please submit such requests in writing to:
        Kendal Jacobson, PT
        Enhanced Performance Therapy
        6010 Balcones, Suite 260
        Austin, TX 78759

Research: Your protected health information will not be used or disclosed for the purposes of research. In the case that you do authorize in writing that your protected health information can be used for research, you will be provided with very specific assurances that your privacy will be protected.

Other Uses and Disclosures: We are permitted and/or required by law to make certain other uses and disclosures of your protected health information without your consent or authorization for the following:

• any purpose required by law
• public health activities, such as required reporting of disease, injury, birth and death, or required public health investigations
• if we suspect child abuse or neglect; if we believe you to be a victim of abuse, neglect, or domestic violence
• to the Food and Drug Administration to report adverse events, product defects, or to participate in product recalls
• to your employer when we have provided health care to you at the request of your employer; to a government oversight agency conducting audits, investigations, or civil or criminal proceedings
• court or administrative ordered subpoena or discovery request
• to law enforcement officials as required by law to report wounds and injuries and crimes
• to coroners and/or funeral directors consistent with law
• if you are a member of the military; we may also release your personal health information for national security or intelligence activities

Your Privacy Rights

Access to Your Protected Health Information: You have the right to request a copy of your medical record. You must make this request in writing by filling out an Authorization to Disclose Health Information form. Any requests that your medical record be sent to a third party of your choosing must also be made through a written request that clearly identifies the relevant third party and grants express permission to release records to that third party.

Amendments to Your Protected Health Information: You have the right to request in writing that an amendment be made to your protected health information. If we disagree with you, we are not required to make the change. You do have the right to submit a written statement about why you disagree that will become a part of your record. We may not amend parts of your medical record that we did not create.

Accounting of Disclosures of Your Protected Health Information: You have the right to receive an accounting of certain disclosures made by us of your protected health information after September 25, 2011. These disclosures will not include those made for treatment, payment, or health care operations, or for which we have obtained authorization.

Restrictions on Use and Disclosure of Your Protected Health Information: You have the right to request restrictions on uses and disclosures of your protected health information for treatment, payment, or health care operations. We are not required to agree to your restriction request, but if we agree, we must abide by your request. Requests must be made in writing and signed by you.

Complaints: If you believe that your privacy rights have been violated, you have the right to make a complaint to us in writing without fear of retaliation. Your complaint should contain enough specific information so that we may adequately investigate and respond to your concerns. If you are not satisfied with our response, you may complain directly to the Secretary of the U.S. Department of Health and Human Services in Washington, D.C.

Our Duty to Protect Your Privacy: We are required to comply with the federal health information privacy regulations by maintaining the privacy of your protected health information. These rules require us to provide you with this Notice of Privacy Practices. We reserve the right to update this notice if required by law. If we do update this notice at any time in the future, the updated notice will be available at www.massagept.com.

Privacy Contact: If you have any questions about this Notice or you would like to file a complaint, please contact:
        Kendal Jacobson
        6010 Balcones, Suite 260
        Austin, TX 78759

I have reviewed and understand the Notice of Privacy Practices for Enhanced Performance Therapy.






Client Signature: ________________________________ Date: __________________________


Click here for printable copy of the Notice of Privacy Practices.