11083 Village Square LN
Fishers, IN 46038
YOUR RIGHTS:You have the following rights regarding Health Information we have about you:
Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you mist make your request, in writing, to Hope PT, LLC 11083 Village Square Lane, Fishers, In. 46038. We have up to 30 days to make your protected Health Information available to you and we may charge you with a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and will comply with the outcome review.
Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is maintained in an electronic format (known as electronic medical record or an electronic health record), you have the right to request that and electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to you Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you requested your record will be provided in either our standard electronic format or if you do not want this form or format, a reasonable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.
Right to Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.
Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the and information. You have the right to request amendment for as long as the information is kept by or for our office. To request and amendment. you must make your request, in writing, to Hope PT, LLC.
Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request and accounting of disclosures, you must make your request , in writing, to Hope PT, LLC.
Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose ti someone involved in your care or the payment for you care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to Hope PT, LLC. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you with to restrict pertains solely to a health care item or service for which you have paid "out-of-pocket" in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Out-of-Pocket-Payment. If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for that purpose of payment or health care operations, and we will honor that request.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to Hope PT, LLC. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.
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 entitled to a paper copy of this notice. You may obtain a copy of this notice at our website, www.hope-pt.com. To obtain a paper copy of this notice, ask anyone in the office.
Changes to This Notice. We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page, in the right hand corner.
Complaints: 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.