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NOTICE OF PRIVACY PRACTICE 

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOUR HEALTHCARE INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 

Our Policy on Medical Record Privacy 

This notice will describe the way our practice will treat medical records we keep regarding your medical care. We are required to keep a record for your care, including your diagnosis, treatment, services you receive, and other information. We are required by law to protect your personal medical record by keeping it private and following certain rules that dictate whether and when we can use or disclose your information. This notice will inform you of these rules. It will also notify you of your rights and our obligations in our use and disclosure of your health information. We are also required to give you notice, and to follow the terms of the notice that is currently in effect. We reserve the right to change this notice, and apply those changes to health information we currently have, as well as information we may receive in the future. If we change this notice, you will receive a new copy of this notice the next time you receive services from our practice. A copy of this notice will be on display in our office. 

Understanding Your Health Record 

Each time you visit Corestar Pilates and Physical Therapy, LLC, a record of your visit is made. Typically, this record contains your symptoms, examination, test results, diagnosis, treatment, and plan for future care and treatment. This information, often referred to as your health or medical record, may serve as a: 

  • Basis for planning your care and treatment 
  • Means of communication among the health professionals who contribute to your care
  • Legal document describing the care you received 
  • Means by which you or a third party payer (such as your insurance company, or HMO) can verify that services billed were actually provided 
  • A source of data for medical research 
  • A source of information for public health officials charged with improving the health of Indiana and the nation 
  • A source of data for planning and marketing 
  • A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve 

Your Rights Regarding Your Health Information 

You have the right to: 

  • Request that we restrict the use or disclosure of your health information for treatment, payment, or healthcare operations (as described in this notice) 
  • Request that we restrict from disclosing information to family or friends ● Request how you would like us to communicate with you 
  • Inspect and copy certain health information, including most of your medical and billing records. This request must be made in writing to Minda Lemmon. A reasonable fee may be applied for copying, postage, or other expenses related to your request.
  • Amend your health record as provided in 45 CFR 164.528 
  • Obtain an accounting of disclosure of your health information as provided in 45 CFR 164.528 
  • Obtain a paper copy of this notice upon request 

NOTE: We are not required to agree to your requests. To request restrictions or limitations, you must make a written request to Minda Lemmon. The request must tell us (1) what information you want to limit; (2) whether you want to limit the use of the information and or disclosure of the information; (3) to whom the limitation or restrictions will apply. 

Our Responsibilities 

Corestar Pilates and Physical Therapy, LLC is required to: 

  • Maintain the privacy of your health information 
  • Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you 
  • Abide by the terms of this Notice 
  • Notify you if we were unable to agree to a requested restriction 
  • Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. 

For More Information or to Report a Problem 

If you have a question and would like additional information, you may contact the practice’s privacy officer: Minda Lemmon (260) 609-2185 

If you believe your privacy rights have been violated, you can file a complaint with the practice’s privacy officer, or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Officer for Civil Rights. The address for the OCR is listed below: 

Office for Civil Rights 

U.S. Department of Health and Human Rights 200 Independence Avenue, S. W. Room 509F, HHH Building 

Washington, D.C. 20201 

How We May Use and Disclose Your Health Information 

We may use and disclose your health information for a number of purposes in connection with your medical care and running our practice. The following lists a number of typical uses and disclosure within our practice. You will not be asked to separately authorize us to do these things. We will use your health information for the following: 

Treatment 

We may use your health information to diagnose your illness or injury, provide you with services, or refer you to another physician. We may disclose your health information to doctors, nurses, technicians, medical students or other personnel who are involved in your care. We also may disclose your health information to people outside of our medical practice who may be involved in medical care, such as family members, clergy, or others. 

Payment 

We may give your health plan information regarding your diagnosis and treatment in order for you to be reimbursed for your office visit. 

Health Care Operations 

We may use or disclose your information if conducting quality assessment and improvement activities to ensure that our patients receive quality medical care. We may also use or disclose your information in training and evaluation of our physicians and other staff, or as part of a medical review, audit, or legal activities. 

Appointment Reminders 

We may use or disclose your information to contact you as a reminder that you have an appointment with our practice. 

Individuals Involved in Your Care or Payment for Your Care 

We may disclose your health information to a family member or friend who is involved in your medical care or who helps pay for your care. We may also tell your family or friends about your condition, for example, if you are admitted to the hospital or in an event of a disaster relief effort. 

Public Health Risk 

We may disclose your health information to report disease, injury or disability; births and deaths; child abuse or neglect; defects, recalls or problems with drugs, medical devices, or other products; to prevent or conditions. We may also notify authorities if we believe you have been the victim of abuse, neglect or domestic violence. If we are required by law to do so, or if you agree to the notification. 

Health Oversight Activities 

We may also disclose your health information to agencies authorized by law for audits, investigations, inspections, and licensure. 

Law Enforcement 

We may disclose your health information when the following circumstances apply:

  • If you have incurred certain injuries or wounds that are legally required to be reported
  • In response to a court order, subpoena, warrant, summons, investigative demands, or similar process 
  • To identify or locate a suspect, fugitive, material witness, or missing person
  • About the victim of a crime if under certain limited circumstances 
  • About a suspicious death that we believe may be the result of criminal conduct
  • About criminal conduct on our premises 
  • In Emergency circumstances to report a crime, its location, or information about the person who may have committed the crime 

Coroners, Medical Examiners, and Funeral Directors 

As necessary to carry out their duties. 

Specialized Government Functions 

We may disclose your health information to release information to military command authorities, upon your separation or discharge from military service to authorized officials. We may also disclose your health information to the appropriate government officials when it is necessary to conduct intelligence or other national security activities authorized by federal law. In addition, we may release your health information if it relates to the protection of the President of the United States or foreign heads of the state. Finally, we may disclose certain information related to members of the armed services and foreign military services to the appropriate personnel. 

Inmates 

If you are an inmate of a correctional facility or under the custody of a law enforcement official, we may disclose your health information to the correctional institution or law enforcement official in order to provide you with medical services, protect you or others, or to ensure safety of the correctional facility. 

Workers’ Compensation for Work Related Illness or Injuries 

We may disclose your health information in relation to worker’ compensation or similar programs established by law that provide benefits for work-related illness or injuries. 

Other Uses of Your Health Information 

We may disclose your health information when required by federal, state or local law, for treatment alternatives or health related benefits/services, organ and tissue donations, or to avert a serious threat to health or safety.