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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.


Transformative Pain Care and Physical Therapy, PLLC (“TPCPT”) is committed to protecting the privacy of your health information. This notice explains how we may use and disclose your Protected Health Information (PHI), your privacy rights, and our legal responsibilities.


HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION


We may use or disclose your PHI without your written authorization when permitted or required by law, including for the following purposes:


Treatment: To provide, coordinate, or manage your health care. For example, we may share information with other health care professionals involved in your care.


Payment: To bill and receive payment for services. For example, we may provide information to your health insurance plan to obtain payment for your treatment.


Health Care Operations: To operate our practice, improve the quality of care, train staff, manage scheduling and billing, and perform other activities necessary to provide and manage health care services.


Appointment Reminders and Health-Related Communications: We may contact you by phone, voicemail, text, email, or mail regarding appointments, scheduling, care coordination, treatment, or other permitted health-related communications.


Other Permitted or Required Disclosures: We may use or disclose PHI when permitted or required by law, including for certain public health activities, health oversight, workers’ compensation, law enforcement requests, judicial or administrative proceedings, required reporting, medical examiners or coroners, and to prevent a serious and imminent threat to health or safety.  We will disclose only the information permitted or required for the applicable purpose.


Other uses and disclosures not described in this notice generally require your written authorization. You may revoke a written authorization as described below.


SPECIAL PROTECTION FOR CERTAIN RECORDS
If TPCPT has substance use disorder patient records that are subject to 42 CFR Part 2, those records will be protected as required by applicable federal law. In general, such records will not be used or disclosed for an investigation or legal proceeding against you without your written consent or a court order and subpoena, as required by law.
TPCPT will also comply with applicable Colorado laws and other federal laws that provide greater privacy protections or impose additional restrictions on the use or disclosure of certain health information.


YOUR PRIVACY RIGHTS
You have the right to:

  • Get a copy of your medical record. You may request a paper or electronic copy of your health information, subject to applicable law.

  • Request correction. You may ask us to correct information you believe is incorrect or incomplete.

  • Ask us to limit what we use or disclose. We are not required to agree to every request. However, if you pay for a service or item completely out-of-pocket and request that we not disclose that information to your health plan for payment or health care operations, we generally must agree unless disclosure is required by law.

  • Request an accounting of certain disclosures. You may request a list of certain disclosures of your health information made during the six years before your request.

  • Get a copy of this notice. You may request a paper copy at any time, even if you agreed to receive it electronically.

  • Choose someone to act for you. If you have a legally authorized personal representative, that person may exercise your rights on your behalf, subject to verification of their authority.

  • File a complaint. You may complain to TPCPT or to the U.S. Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint.

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YOUR AUTHORIZATION
Some uses or disclosures of PHI require your written authorization. You may revoke an authorization in writing at any time, except to the extent TPCPT has already acted in reliance on it or as otherwise permitted by law.


OUR RESPONSIBILITIES
TPCPT is required by law to:

  • Maintain the privacy and security of your PHI.

  • Provide you with this notice describing our legal duties and privacy practices.

  • Follow the privacy practices described in the current notice.

  • Notify affected individuals when required by law following a breach of unsecured PHI.

  • Provide you with a copy of this notice upon request.

We may change the terms of this notice. Any revised notice will apply to the PHI we maintain and will be available at our office.


ELECTRONIC COMMUNICATIONS
TPCPT uses electronic systems to support patient care and practice operations, including electronic health records, email, text messaging, telephone, voicemail, fax, and electronic payment systems.


We may use your phone number to send text messages related to appointments, scheduling, care coordination, treatment, or other permitted health-related communications. We do not sell, rent, or lease your personal information. We do not sell, rent, or share mobile phone numbers or SMS opt-in consent with third parties or affiliates for marketing or promotional purposes. We may share your phone number with service providers who help us deliver our services, including SMS messaging, but only as necessary to provide those services.


We use reasonable safeguards to protect your information. However, electronic communications carry inherent risks, including the possibility of misdirected, intercepted, or inadvertently disclosed information.

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QUESTIONS, COMPLAINTS, OR PRIVACY CONCERNS
If you have questions about this notice or believe your privacy rights have been violated, please contact:

 

Shiree Johnson, Director of Operations
Transformative Pain Care and Physical Therapy, PLLC
1410 Valley View Dr. #309
Delta, CO 81416
Phone: 970-639-1948
Email: paindrkevin@transformativepain.com

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ACKNOWLEDGMENT OF RECEIPT
I acknowledge that I have received or have been offered an opportunity to receive a copy of TPCPT’s Notice of Privacy Practices.
Patient Name: ______________________________________________________
Patient/Representative Signature: ______________________________________
Date: ______________________


If signed by representative: ___________________________________________
Relationship to Patient: ______________________________________________
If acknowledgment was not obtained, reason:
 
 

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