WP E-Signature by Approve Me - Sign Documents Using WordPress -

Notice of Privacy Practices

Your Information.
Your Rights.
Our Responsibilities.

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.

YOUR RIGHTS
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say "no" to your request, but we'll tell you why in writing within 60 days.

Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say "yes" to all reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment, or our operations.
We are not required to agree to your request, and we may say "no" if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
We will say "yes" unless a law requires us to share that information.

Get a list of those with whom we've shared information

You can ask for a list accounting of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one account a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive this notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

If you have given someone medical power of attorney of if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us using the information on page 1.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to:
- 200 Independence Avenue, S.W., Washington, D.C., 20201
- Calling 1-877-696-6775
- or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html
We will not retaliate against you for filing a complaint.

YOUR CHOICE
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and will will follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care.
Share information in a disaster relief situation.
Include your information in a hospital directory.
Contact you for fundraising efforts.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases, we never share your information unless you give us written permission:

Marketing purposes
Sale of your information
Most sharing of psychotherapy notes

OUR USES AND DISCLOSURES
How do we typically use or share your health information? We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: https://www.hhs.gov/hipaa/index.html. We typically use or share your health information in the following ways:

Treat you

We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.

For Diagnostics

We can share your health information with our Diagnostic mentors.
Example: We give information about you to Doctors whom help interpret our diagnostic tests.

Help with public health and safety issues

We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone's health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federals laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.

Respond to organ tissue donations request

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers' compensation, law enforcement, and other government requests

We can use or share health information about you:
- For workers' compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena

OUR RESPONSIBILITIES

We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see:

Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Effective Date of this Notice: 11/11/2019

I have read the above HIPAA Notice of Privacy Practices and understand its contents

Are you a minor? Yes No

Parent/legal Guardian or Representative
Date

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

January 27, 2020 11:42 am AKST

Notice of Privacy Practices Uploaded by Jaimee Watson - jaimee@ohwpt.com IP 206.223.197.206

June 8, 2020 3:31 pm AKST

Nikki Brown - nikki@ohwpt.com added by Christopher Comstock - emily@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

August 28, 2020 9:37 am AKST

Nikki Brown - nikki@ohwpt.com added by Optimum Health and Wellness - emily@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

July 1, 2021 4:31 pm AKST

Stephanie Cain - stephanie@ohwpt.com added by Optimum Health and Wellness - nikki@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

July 9, 2021 5:06 pm AKST

Elizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - nikki@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

July 9, 2021 5:06 pm AKST

Elizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - nikki@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

February 4, 2022 12:36 pm AKST

Elizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - jaimee@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

March 15, 2022 10:59 am AKST

Jaimee Watson - jaimee@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

March 15, 2022 10:59 am AKST

Elizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

March 30, 2022 8:27 am AKST

Elizabeth McCallister - elizabeth@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

March 30, 2022 8:27 am AKST

Jaimee Watson - jaimee@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

May 31, 2022 3:30 pm AKST

Annie Morris - annie@ohwpt.com added by Optimum Health and Wellness - elizabeth@ohwpt.com as a CC'd Recipient Ip: 206.223.197.206

May 31, 2022 3:31 pm AKST

Document owner elizabeth@ohwpt.com has handed over this document to jaimee@ohwpt.com 2022-05-31 15:31:56 - 206.223.197.206

May 31, 2022 3:31 pm AKST