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.
This notice is presented to you as required by federal law as of the effective date.
If you have any questions about this notice, please contact PT Revolution.
Who Will Follow This Notice
This notice describes our office’s practices. We may share information with each other for your care.
Our Pledge Regarding Medical Information
We understand that medical information about you and your health is personal. We are committed to protecting your medical information. We create a record of the care you receive at this office to provide you with quality care and to comply with legal requirements. This notice will tell you about the ways in which we use and disclose your medical information. We also describe your rights and the obligations we have regarding the use and disclosure of medical information. We are required by law to make sure that medical information that identifies you is kept private; give you this notice of our privacy practices with respect to your medical information; and follow the terms of the current notice.
How We May Use and Disclose Medical Information About You:
We may use information about you to provide you with medical treatment. We may disclose medical information about you to office staff and others involved in your care.
We may use and disclose information about you for insurance and payment services.
For Health Care Operations
We may use and disclose information about you for practice operations to make sure that you receive quality care and for learning purposes.
We may use and disclose information to contact you about appointments.
We may call or text and leave messages on your device or with whoever answers the phone at your house or on your voicemail unless directed otherwise.
We may use and disclose information to tell you about treatment options.
Health-Related Benefits and Services
We may tell you about health-related benefits or services.
Individuals Involved in Your Care or Payment for Your Care
We may release medical information about you to a friend or family member who is involved in or helps pay for your medical care. We may disclose medical information about you to assist in a disaster relief effort.
As Required By Law
We will disclose information about you when required to do so by law.
To Avert a Serious Threat to Health or Safety
We may use and disclose information about you to prevent a serious threat to your health and safety, the public or to another person.
Organ and Tissue Donation
If you are an organ donor, we may release information to organ banks.
Military and Veterans
We may release information about military personnel as required.
We may release information about you for workers’ compensation.
Public Health Risks
We may disclose information about you for public health activities.
Health Oversight Activities
We may disclose information to a health oversight agency.
Lawsuits and Disputes
We may disclose information about you in response to a court or administrative order, a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request.
We may release information to a law enforcement official as required by law.
Coroners, Medical Examiners and Funeral Directors
We may release information to a coroner, medical examiner or funeral director as necessary.
National Security and Intelligence Activities and Protective Services for the President
We may release information about you to authorized federal officials for national security activities.
We may release information about inmates to a correctional institution or law enforcement.
You have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy
You have the right to inspect and copy your medical information. This includes medical and billing records, but does not include psychotherapy notes. You must submit your request in writing to PT Revolution at the address above. We may charge a fee for the costs of copying. We may deny your request to inspect and copy. You may request that the denial be reviewed. Another neutral health care professional, not the person who denied your request, will review your request and the denial. We will comply with the outcome of the review.
Right to Amend
If you feel that your information is incorrect or incomplete, you may ask us to amend the information. You may request an amendment as long as the office has this information. Your request must include the reason, be made in writing and submitted to PT Revolution. We may deny your request if you ask us to amend information not created by us, unless the person that created the information is no longer available; is not part of the information kept by the practice; is not information which you would be permitted to inspect and copy; or is accurate and complete.
Right to an Accounting of Disclosures
You have the right to request a list of the accounting of disclosures we made of your medical information. You must submit your request in writing to PT Revolution. Your request must state a time period, not longer than six years, and indicate whether you want the list on paper or electronic. Your first requested list within a year is free.
Right to Request Restrictions
You have the right to request a restriction or limitation on the information we use or disclose about you for treatment, payment, and health care operations or to someone who is involved in your care or the payment for your care. We are not required to agree to your request. If we agree, we will comply with your request unless the information is needed in an emergency. You must make your request in writing to PT Revolution. You must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.
Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or location. You must make your request in writing to PT Revolution. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. We have the right to deny your request.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, request verbally or in writing to any PT Revolution staff.
Changes to this Notice
We reserve the right to change this notice and make the revised notice effective for information we already have about you as well as any future information. We will post a copy of the current notice in the office. Each time you register at the office we will offer you a copy of the current
If you believe your privacy rights have been violated, you may file a complaint with our office or
with the Secretary of the Department of Health and Human Services. To file a complaint with the
office, contact PT Revolution at 2038 Lake Tahoe Blvd, South Lake Tahoe, CA 96150 or email to firstname.lastname@example.org. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Other Uses of Medical Information
Other uses and disclosures of information not covered by this notice will be made only with your written permission. You may revoke that permission in writing at any time. Understand that we are unable to take back any permitted disclosures, and that we are required to retain records of your care.