The Movement Studio
Mary Gorman, PT
309 S Pacific Hwy
Talent OR, 97540
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY.
The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our facility and provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you.
By law, we are required to:
- Keep your medical information private.
- Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.
We have the right to change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law. Any new information will be provided to you.
USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
The following section describes different ways that we use and disclose medical information. Not every use of disclosure will be listed.
For Treatment: We may use your medical information for medical treatment of services. We may disclose medical information (ROI) about you to doctors, nurses, technicians, medical students, lawyers re MVA, or other people who are taking care of you.
For Payment: We may use and disclose your medical information for obtaining payment on our services.
For Health Care Operations: We may use your medical information to perform certain functions within our facility.
In addition to using and disclosing your medical information for treatment, payment, and healthcare operations, we may use and disclose medical information for the following purposes.
Unless you notify us that you object, the following medical information about you will be placed in our client database.
- Your Name
- Your Address
- Your Phone Number
We may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful processes. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials.
We may disclose medical information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or the possible victim of other crimes. Also if you are committing self-harm, child or elder abuse.
We may disclose medical information (ROI) when authorized and necessary to comply with laws relating to workers' compensation, MVA, or other similar programs.
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding your health information which we create and/or maintain.
- You have the right to review and copy medical information that may be used to make decisions about your care. You must request this information in writing. (If you request copies there will be a charge of $2/page + postage)
- You have a right to know with whom we have shared your medical information.
- You have a right to request restriction of uses and disclosures and communicating medical information.
QUESTIONS AND COMPLAINTS
If you have any questions about this notice, please contact our office. If you think that we may have violated your privacy rights, please contact our office. You may submit a written complaint to the US Department of Health and Human Services.
By signing below, you agree to the terms you have initialed, have reviewed the Notice of Privacy Practices, and have completed the above fields truthfully and to the best of your knowledge.