In compliance with a newly enacted Federal Law, the Health Insurance Portability and Accountability Act (HIPAA), Premier Rehabilitation is informing you of your privacy rights. Please review the information below. HIPAA is a law passed by Congress in 1996 to improve the efficiency and effectiveness of the healthcare system. It requires health care professionals to adhere to privacy and security standards in order to protect their patient’s Personal Health Information (PHI). PHI is confidential information about a patient, including demographic information. What are my rights under HIPAA? Under HIPAA you have a right to request the following as long as a request is made in writing to the attention of the Privacy Officer and applicable fees are paid. There is a possibility that your request may be denied. If your request is denied we will explain why it was denied in writing.

• You have a right to inspect and obtain a copy of your PHI. We will respond to your request within 30 days. In most cases your request will be honored and a copy of your PHI will be mailed to you.
• You have a right to request an amendment of PHI. If you feel that your PHI is inaccurate or incomplete, you may request an amendment to your PHI. We will respond to your request within 60 days. If we honor your request
  we will amend your PHI and notify you and applicable parties. We will deny your request if we determine your PHI to be correct or complete, if your request was not created by us, or if PHI is not available for inspection.
• You have the right to know what disclosure(s) of your PHI have been made. You have a right to request a listing of who your PHI was sent to, when it was sent, what content of your PHI was sent and for what purpose. We will respond to your request within 60 days. There will be no charge to you for an initial request. Additionally, your request may not include disclosures made for national security reasons, to law enforcement officials/correctional facilities, or disclosures made prior to April 14, 2003.
• You have a right to request confidential communications of PHI. We will honor all reasonable requests to keep communications confidential. A reasonable request is one that specifies an alternative address, gives other
  means of contact and provides detailed information on how payment will be handled.
• You have a right to request restrictions on the use and disclosure of PHI, however we are not required to agree to your request. Your request must state specific restrictions requested & to whom the restrictions would apply.
• You have a right to receive a hard copy of this notice.

How will Premier Rehabilitation Use and Disclose PHI under HIPAA? HIPAA allows us to use and disclose your PHI for the purposes of Treatment, Payment and Healthcare Operations. We will specifically use and disclose your PHI to communicate with your physician and to, upon request, assist your insurance company with the processing of your claims. Additionally, we will use your basic demographic information to notify you of new services or facilities. Your authorization is not required for Use and Disclosure of PHI for the purposes of Treatment, Payment and Healthcare Operations. Listed are other instances in which Use and Disclosure of your PHI is allowed without your authorization. 

• Disclosure to those Involved in the Individual’s Care – when necessary, we will make a professional decision to disclose PHI to family members, close friends or other persons involved in and assisting in your care when you approve or when are not able or present to approve. 

• Uses and Disclosures Required by Law – as required by law we are required to use and disclose PHI for the following reasons: 

• Use and Disclose PHI for Public Health Activities – Examples include: communicable diseases, sexually transmitted diseases, lead poisoning, Reyes Syndrome, etc., to public health officials. 
• Disclose PHI about Victims of Abuse, Neglect, or Domestic Violence - Examples include: child abuse and
  neglect; an abused or neglected nursing home resident; a patient over 60 years old involved in elder
  abuse.
• Uses and Disclosure of Health Oversight Activities – we may use and release PHI to be used for audits,
  investigations, licensure issues, etc.
• Disclosure for Judicial and Administrative Proceedings – we may disclose limited PHI to the appropriate
  authorities as a result of a court order subpoena, discovery request, etc.
• Disclosure for Law Enforcement Purposes – we may disclose reasonably necessary PHI to law enforcement officials to identify or locate a suspect, fugitive, material witness or missing person.
• Uses and Disclosures Related to Decedents – we may use and disclose PHI to a coroner or medical examiner and funeral directors as required by law.
• Uses and Disclosures Related to Cadaveric Organ, Eye or Tissue Donations – we may use and release PHI in order to facilitate organ, eye or tissue donations.
• Uses and Disclosures to Avert a Serious Threat to Health or Safety – we may use & release PHI to public health & other authorities required by law in order to prevent a serious threat to your health or safety.
• Uses and Disclosures for Specialized Government Functions – we may use and release PHI for military/veterans activities and national security/intelligence activities.
• Use and Disclosure of PHI in Emergency Situations - in the event of an eminent threat to the safety of a
  patient, we may disclose PHI to prevent or lessen the threat.

• Uses and Disclosures of PHI for Marketing Purposes – Premier Rehabilitation will notify you of new services and facilities unless you specify otherwise. Unless you authorize such a disclosure we will not disclose your PHI for marketing purposes. 

• Uses and Disclosures of PHI for Research Purposes – we do not use or disclose identifiable PHI for research purposes, unless you authorize such use and disclosure. 

• Uses and Disclosures requiring the Patients Authorization - we must obtain your written authorization if we are interested in using and or disclosing your PHI for reasons other than treatment, payment and health care operations. You may revoke your authorization at any time.

What does HIPAA require of Premier Rehabilitation? Premier Rehabilitation must maintain the privacy of PHI, abide by the terms of this notice and provide patients with a revised notice, if necessary. 

Where can I file a privacy complaint? If you feel your privacy rights have been violated, contact Premier Rehabilitation’s Privacy Officer, Jeffrey Cook, 517-709-4677. Or contact the regional Department of Health and Human Services at 312-886- 2359 or www.hhs.gov. 

Receipt of Notice of Privacy Practices Form: I, hereby acknowledge receipt of Premier Rehabilitation’s Notice of Privacy Practices. Premier Rehabilitation will use or disclose my PHI for the purposes of carrying out treatment, payment and health care operations. The Notice of Privacy Practices provides detailed information about how the practice may use and disclose my confidential information. I understand Premier Rehabilitation has reserved a right to change its privacy practices that are described in the Notice. I also understand a copy of any Revised Notice will be provided to me or made available at my next office visit. I give my consent for Premier Rehabilitation to notify me of new facilities or services. I understand that I may revoke this consent at any time by giving written notice of my desire to do so, to Premier Rehabilitation.

Authorizations & Releases

The undersigned acknowledges that he or she personally has the ability to review and/or receive a copy of the Notice of Privacy Practices from Premier Rehabilitation.

I, the undersigned, hereby authorize and instruct my insurance company, adjuster, rehabilitation representative, attorney, social worker, employer, and other payer, or myself to pay any and all benefits/monies directly to Premier Rehabilitation for any services rendered to me due to accident or illness. In addition, I fully understand I am responsible for any amount not covered by my insurance.

I, the undersigned, herby consent to and authorize Premier Rehabilitation to administer physical therapy, occupational therapy, speech therapy, and/or cardiac therapy treatment to me for which I am responsible. I have been informed by my physician as to the nature and the purposes for which these therapies are to be performed and administered by Premier Rehabilitation. However, I do acknowledge there may be additional procedures as deemed necessary on the basis of findings during the course of said treatment. I consent to such procedures after an explanation has been given of their nature and purpose. In addition, I acknowledge results are contingent on my participation in the treatment, though are still not guaranteed.

Please list any other parties who can have access to your health information. (This includes step parents, grandparents, and any care takers who can have access to this patient’s records):