HIPPA Policy

HIPAA Notice of Privacy Practices 

With ARRA Amendments of 2009.

Align Physical Therapy and Wellness, LLC

Notice of Privacy Practices



Effective date: 10/20/23

If you have any questions about this notice, please contact our privacy officer:

Leah Hultstrom, PT, DPT


1. Summary of Rights and Obligations Concerning Health Information. Align Physical Therapy & Wellness,

LLC is committed to preserving the privacy and confidentiality of your health information, which is required both by federal

and state law. We are required by law to provide you with this notice of our legal duties, your rights, and our privacy

practices, with respect to using and disclosing your health information that is created or retained by Align Physical

Therapy & Wellness, LLC. Each time you visit us, we make a record of your visit. Typically, this record contains your

symptoms, examination and test results, our assessment of your condition, a record of your treatment interventions, and a

plan for future care or treatment. We have an ethical and legal obligation to protect the privacy of your health information,

and we will only use or disclose this information in limited circumstances. In general, we may use and disclose your health

information to:

• plan your care and treatment;

• provide treatment by us or others;

• communicate with other providers such as referring physicians;

• receive payment from you, your health plan, or your health insurer;

• make quality assessments and work to improve the care we render and the outcomes we achieve,

known as health care operations;

• make you aware of services and treatments that may be of interest to you; and

• comply with state and federal laws that require us to disclose your health information.

We may also use or disclose your health information where you have authorized us to do so.

Although your health record belongs to Align Physical Therapy & Wellness, LLC, the information in your record belongs to

you. You have the right to:

• ensure the accuracy of your health record;

• request confidential communications between you and your physician and request limits on the use and

disclosure of your health information; and

• request an accounting of certain uses and disclosures of health information we

have made about you.

We are required to:

• maintain the privacy of your health information;

• provide you with notice, such as this Notice of Privacy Practices, as to our legal duties and privacy practices with

respect to information we collect and maintain about you;

• abide by the terms of our most current Notice of Privacy Practices;

• notify you if we are unable to agree to a requested restriction; and

• accommodate reasonable requests you may have to communicate health

information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions effective for all your health

information that we maintain.

Should our information practices change, a revised Notice of Privacy Practices will be available upon request. If there is a

material change, a revised Notice of Privacy Practices will be distributed to the extent required by law. We will not use or

disclose your health information without your authorization, except as described in our most current Notice of Privacy

Practices. In the following pages, we explain our privacy practices and your rights to your health information in more


If you have limited proficiency in English, you may request a Notice of Privacy Practices in [your language(s)].

2. We may use or disclose your medical information in the following ways:

Treatment. We may use and disclose your protected health information to provide, coordinate and manage

your rehab care. That may include consulting with other health care providers about your health care or

referring you to another health care provider for treatment including physicians, nurses, and other health care

providers involved in your care. For example, we may we will release your protected health information to a

specialist to whom you have been referred to ensure that the specialist has the necessary information he or

she needs to diagnose and/or treat you.

Payment. We may use and disclose your health information so that we may bill and collect payment for the

services that we provided to you. For example, we may contact your health insurer to verify your eligibility for

benefits, and may need to disclose to it some details of your medical condition or expected course of

treatment. We may use or disclose your information so that a bill may be sent to you, your health insurer, or a

family member. The information on or accompanying the bill may include information that identifies you and

your diagnosis, as well as services rendered, any procedures performed, and supplies used. If, however, you

pay cash at the time of service, we will not disclose your protected health information to your health plan or

any other responsible payer unless you sign an authorization for us to do so. If we agree to await payment

from your health plan or put you on a payment plan, we may provide health information to a collection agency,

small claims court or other court of competent jurisdiction in the event your claims for our services are not

paid within 90 days and you have not made alternative payment arrangements with us.

Health Care Operations. We may use and disclose your health information to assist in the operation of our

practice. For example, we may use information in your health record to assess the care and outcomes in your

case and others like it as part of a continuous effort to improve the quality and effectiveness of the healthcare

and services we provide. We may use and disclose your health information to conduct cost-management and

business planning activities for our practice.

Business Associates. Align Physical Therapy & Wellness, LLC sometimes contracts with third-party

business associates for services. Examples include answering services, transcriptionists, billing services,

consultants, and legal counsel. We may disclose your health information to our business associates so that

they can perform the job we have asked them to do. To protect your health information, however, we require

our business associates to appropriately safeguard your information.

Appointment Reminders. We may use and disclose Information in your medical record to contact you as a

reminder that you have an appointment. We usually will text you on your cell phone and email three days before

your appointment, one day before and one hour before. You may opt out of appointment reminders via Square.

Treatment Options. We may use and disclose your health information in order to inform you of alternative


Release to Family/Friends. Our staff, using their professional judgment, may disclose to a family member, other

relative, close personal friend or any other person you identify, your health information to the extent it is relevant

to that person’s involvement in your care or for payment related to your care. We will provide you with an

opportunity to object to such a disclosure whenever we practicably can do so. We may disclose the health

information of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law.

However, please note that state law may prohibit us from disclosing medical information to a parent or guardian at

the child’s request if the child is of a certain age.

Health-Related Benefits and Services. We may use and disclose health information to tell you about

health-related benefits or services that may be of interest to you. In face- to-face communications, such as

appointments with your provider, we may tell you about other products and services that may be of interest

you. Upon request, this information may be emailed or texted to you.

Newsletters and Other Communications. We may use your personal information in order to communicate

to you via newsletters (including electronic newsletters – subject to applicable anti-spam laws), mailings, or

other means regarding treatment options, health related information, disease management programs,

wellness programs, or other community based initiatives or activities in which our practice is participating.

Disaster Relief. We may disclose your health information in disaster relief situations where disaster relief

organizations seek your health information to coordinate your care, or notify family and friends of your location

and condition. We will provide you with an opportunity to agree or object to such a disclosure whenever we

practicably can do so.

Marketing. In most circumstances, we are required by law to receive your written authorization before we

use or disclose your health information for marketing purposes. However, we may provide you with

promotional gifts of nominal value and market services or products to you in face-to-face communications.

Under no circumstances will we sell our patient lists or your health information to a third party without your

written authorization.

Fundraising. We may use certain information (name only, address, telephone number, date of service, age

and gender) to contact you as part of fundraising efforts our practice participates in. If you do not wish to be

contacted about our fundraising activities, please notify us or our privacy officer.

Public Health Activities. We may disclose medical information about you for public health activities. These

activities generally include the following:

• licensing and certification carried out by public health authorities;

• prevention or control of disease, injury, or disability;

• reports of births and deaths;

• reports of child abuse or neglect;

• notifications to people who may have been exposed to a disease or may be at

risk for contracting or spreading a disease or condition;

• organ or tissue donation; and

• notifications to appropriate government authorities if we believe a patient has

been the victim of abuse, neglect, or domestic violence. We will make this

disclosure when required by law, or if you agree to the disclosure, or when

authorized by law and in our professional judgment disclosure is required to

prevent serious harm.

Food and Drug Administration (FDA). We may disclose to the FDA and other regulatory agencies of the

federal and state government health information relating to adverse events with respect to food, supplements,

products and product defects, or post-marketing monitoring information to enable product recalls, repairs, or


Workers Compensation. We may disclose your health information to the extent authorized by and to the

extent necessary to comply with laws relating to workers’ compensation or other similar programs established

by law.

Law Enforcement. We may release your health information:

• in response to a court order, subpoena, warrant, summons, or similar process of authorized under state or

federal law;

• to identify or locate a suspect, fugitive, material witness, or similar person;

• about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s


• about a death we believe may be the result of criminal conduct;

• about criminal conduct at [name of provider];

• to coroners or medical examiners;

• in emergency circumstances to report a crime, the location of the crime or

victims, or the identity, description, or location of the person who committed the crime;

• to authorized federal officials for intelligence, counterintelligence, and other national security authorized by

law; and

• to authorized federal officials so they may conduct special investigations or provide protection to the

President, other authorized persons, or foreign heads of state.

De-identified Information. We may use your health information to create "de-identified" information or we

may disclose your information to a business associate so that the business associate can create de-identified

information on our behalf. When we "de-identify" health information, we remove information that identifies you

as the source of the information. Health information is considered "de-identified" only if there is no reasonable

basis to believe that the health information could be used to identify you.

Personal Representative. If you have a personal representative, such as a legal guardian, we will treat that

person as if that person is you with respect to disclosures of your health information. If you become

deceased, we may disclose health information to an executor or administrator of your estate to the extent that

person is acting as your personal representative.

Limited Data Set. We may use and disclose a limited data set that does not contain specific readily

identifiable information about you for research, public health, and health care operations. We may not

disseminate the limited data set unless we enter into a data use agreement with the recipient in which the

recipient agrees to limit the use of that data set to the purposes for which it was provided, ensure the security

of the data, and not identify the information or use it to contact any individual.

3. Authorization for Other Uses of Medical Information. Uses of medical information not covered by our most current

Notice of Privacy Practices or the laws that apply to us will be made only with your written authorization. You should be

aware that we are not responsible for any further disclosures made by the party you authorize us to release information to.

If you provide us with authorization to use or disclose medical information about you, you may revoke that authorization, in

writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for

the reasons covered by your written authorization, except to the extent that we have already taken action in reliance on

your authorization or, if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has

the right to contest a claim or the insurance coverage itself. We are unable to take back any disclosures we have already

made with your authorization, and we are required to retain our records of the care that we provided to you.

4. Your Health Information Rights. You have the following rights regarding medical information we gather about you:

A. Right to Obtain a Paper Copy of This Notice. You have the right to a paper copy of this Notice of Privacy

Practices at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper


B. Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to

make decisions about your care. This includes medical and billing records.

To inspect and copy medical information, you must submit a written request to our privacy officer. We will supply

you with a form for such a request. If you request a copy of your medical information, we may charge a

reasonable fee for the costs of labor, postage, and supplies associated with your request. We may not charge you

a fee if you require your medical information for a claim for benefits under the Social Security Act (such as claims

for Social Security, Supplemental Security Income, and any other state or federal needs-based benefit program.

If your medical information is maintained in an electronic health record, you also have the right to request that an

electronic copy of your record be sent to you or to another individual or entity. We may charge you a reasonable

cost based fee limited to the labor costs associated with transmitting the electronic health record.

C. Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may

ask us to amend the information. You have the right to request an amendment for as long as we retain the


To request an amendment, your request must be made in writing and submitted to our privacy officer. In addition,

you must provide a reason that supports your request. We may deny your request for an amendment if it is not in

writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to

amend information that:

• was not created by us, unless the person or entity that created the information is no longer available to make the


• is not part of the medical information kept by or for [name of provider];

• is not part of the information which you would be permitted to inspect and copy; or

• is accurate and complete.

If we deny your request for amendment, you may submit a statement of disagreement. We may reasonably limit

the length of this statement. Your letter of disagreement will be included in your medical record, but we may also

include a rebuttal statement.

D. Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures of your

health information made by us. In your accounting, we are not required to list certain disclosures, including:

• disclosures made for treatment, payment, and health care operations purposes or disclosures made incidental

to treatment, payment, and health care operations, however, if the disclosures were made through an electronic

health record, you have the right to request an accounting for such disclosures that were made during the

previous 3 years;

• disclosures made pursuant to your authorization;

• disclosures made to create a limited data set;

• disclosures made directly to you.

To request an accounting of disclosures, you must submit your request in writing to our privacy officer. Your

request must state a time period which may not be longer than six years and may not include dates before April

14, 2003. Your request should indicate in what form you would like the accounting of disclosures (for example, on

paper or electronically by e-mail). The first accounting of disclosures you request within any 12-month period will

be free. For additional requests within the same period, we may charge you for the reasonable costs of providing

the accounting of disclosures. We will notify you of the costs involved and you may choose to withdraw or modify

your request at that time, before any costs are incurred. Under limited circumstances mandated by federal and

state law, we may temporarily deny your request for an accounting of disclosures.

E. Right to Request Restrictions. You have the right to request a restriction or limitation on the medical

information we use or disclose about you for treatment, payment, or health care operations. If you paid out-ofpocket

for a specific item or service, you have the right to request that medical information with respect to that

item or service not be disclosed to a health plan for purposes of payment or health care operations, and we are

required to honor that request. You also have the right to request a limit on the medical information we

communicate about you to someone who is involved in your care or the payment for your care.

Except as noted above, we are not required to agree to your request. If we do agree, we will comply with your

request unless the restricted information is needed to provide you with emergency treatment. To request

restrictions, you must make your request in writing to our privacy officer. In your request, you must tell us:

• what information you want to limit;

• whether you want to limit our use, disclosure, or both; and

• to whom you want the limits to apply.

F. 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 at work or by e-mail. To request confidential communications, you must make your request in writing to your

provider or our privacy officer. We will not ask you the reason for your request. We will accommodate all

reasonable requests. Your request must specify how or where you wish to be contacted.

G. Right to Receive Notice of a Breach. We are required to notify you by first class mail or by e-mail (if you

have indicated a preference to receive information by e-mail), of any breaches of Unsecured Protected Health

Information as soon as possible, but in any event, no later than 60 days following the discovery of the breach.

“Unsecured Protected Health Information” is information that is not secured through the use of a technology or

methodology identified by the Secretary of the U.S. Department of Health and Human Services to render the

Protected Health Information unusable, unreadable, and undecipherable to unauthorized users. The notice is

required to include the following information:

• a brief description of the breach, including the date of the breach and the date of its discovery, if known;

• a description of the type of Unsecured Protected Health Information involved in the breach;

• steps you should take to protect yourself from potential harm resulting from the breach;

• a brief description of actions we are taking to investigate the breach, mitigate losses, and protect against further


• contact information, including a toll-free telephone number, e-mail address, Web site or postal address to permit

you to ask questions or obtain additional information. In the event the breach involves 10 or more patients

whose contact information is out of date we will post a notice of the breach on the home page of our Web site or

in a major print or broadcast media. If the breach involves more than 500 patients in the state or jurisdiction, we

will send notices to prominent media outlets. If the breach involves more than 500 patients, we are required to

immediately notify the Secretary. We also are required to submit an annual report to the Secretary of a breach

that involved less than 500 patients during the year and will maintain a written log of breaches involving less

than 500 patients.

5. Complaints. If you believe your privacy rights have been violated, you may file a complaint with us or with the

Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201.

To file a complaint with us, contact our privacy officer at the address listed above. All complaints must be submitted in

writing and should be submitted within 180 days of when you knew or should have known that the alleged violation

occurred. See the Office for Civil Rights website, www.hhs.gov/ocr/hipaa/ for more information. You will not be penalized

for filing a complaint.