Notice of Patient Privacy Practices and Rights
Name of Practice: Prismatic Pelvic Health, PLLC
This notice describes how medical information about you may be disclosed and used, and how
you can get access to this information. Please read carefully.
Your basic rights and our basic responsibilities under HIPAA. Patients of this practice have
the right to obtain a copy of paper or electronic medical records, make corrections to the record,
request confidential communication, request that we limit the information we share, get a list of
entities with whom we have shared your information, get a copy of this notice, choose someone
to act on your behalf, and file a complaint if you believe your privacy rights have been violated.
Get a copy (paper or electronic) of your records. We will provide a copy of your record, and
can charge you 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 incomplete or incorrect.
Request preferred confidential communications. You can ask us to contact you by a preferred
method ( ie. Home/office/cell) or ask to send mail to a specified address.
Limit what we share or use. You can ask us not to share or use certain health information for
our operations, treatment or payment, although we are allowed to refuse your request if it would
affect your care. If you pay for a service out of pocket in full, you can ask us not to share that
with your health insurer, and we will comply unless a law requires us to share that information.
Get a list of those with whom we have shared information. Upon request you are entitled to
receive a list of the times we have shared your health information, who we shared it with, and
why for up to six years prior to the date you asked. We will include all the disclosures except
those about treatment, payment and health care operations, and certain other disclosures, such as
any you requested. There is no charge for a yearly request of this list, but there is a reasonable
cost based fee if such list is requested more than once in a 12 month period.
Get a hard copy of this privacy notice. Upon request, you can receive a paper copy of this
notice, if you have previously received this electronically.
Choose someone to act on your behalf. If someone is your legal guardian, or has medical
power of attorney for you, that person can exercise your rights and make choices about your
healthcare information. We will verify that any person has the authority to act on your behalf
before taking any action.
File a complaint if you think your rights are violated. If you feel your rights have been
violated, please contact us (info on page 1). You can file a complaint with the US Dept of Health
and Human Services Office of Civil Rights by visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/, calling 877.696.6775 or writing to: US Dept of H
and H Services, Office of Civil Rights, 200 Independence Avenue, S.W. Washington, D.C.
20201. We will not retaliate against you for filing a complaint.
Your Basic choices and our basic responsibilities under HIPAA. For certain health care
information, you can tell us your choices about what we share. You can tell us whether to share
information with your family, close friends, others involved in your care. You can tell us
whether to share information in a disaster relief situation. We will never share your information
for the sale of the information or for marketing purposes unless we have express written
permission. We can contact you in the case of fundraising, but you can tell us not to contact you
again.
Our use and disclosures of your health information to treat you, run our practice or bill for
your services. We may use and share your health information to treat you and share with others
who are treating you. Ex – a child being treated by multiple therapists and disciplines. We can
use and share your health information to run our practice, improve your care and contact you
when necessary. We can use and share your health information to bill and get payment from
health plans or other entities. Ex- we give information to your insurer so they will pay for our
services. Please note that Prismatic Pelvic Health, PLLC is not an in-network provider. See
financial policy via the informed consent form.
Other ways we may share or use your health information. We are required (upon request) to
share your information in other ways that contribute to the public good, such as public health and
research. These conditions are stringent and regulated by many laws before any information can
be shared.
Help with safety and public health issues. We can share health information about you for
certain situations such as preventing disease, helping with product recall, reporting adverse
reactions to medications, reporting suspected abuse, neglect or domestic violence, preventing or
mitigating a serious threat to someone’s health or safety.
Do research. We can use or share your information for health research.
Respond to organ and tissue donation requests. We can share health information about you
with organ procurement organizations.
Work with a medical examiner or funeral director. We can share information upon request
when an individual dies.
Comply with the law, respond to any legal action. We will share information about you if state
or federal law requires it, including any audits conducted by the Dept. of Health and Human
Services. We can share information about you in response to a court or administrative order or in
response to a subpoena.
Comply with worker’s compensation, law enforcement, other gov’t requests. Information
about you can be shared for worker’s comp claims, law enforcement purposes, health oversight
agencies for activities authorized by law, and for special government functions such as military,
national security, and presidential protective services.
Blue Button protocol. Any patients with medical care managed by the Blue Button protocol can
learn more about access to their health information at
http://www.hhs.gov/digitalstrategy/open-data/introducing-blue-button-plus.html
Summary of 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 will give you a hard copy of
this notice and follow the duties and privacy practices described in this notice. We will not use
or share your information other than as described here unless you tell us we can in writing that
we can. You may also change your mind at any time and let us know in writing if you do.
Additional info is available at:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
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,
on our website and in our office.
Effective date: March 1, 2022
Privacy Officer: Rachel Thennes, MOT, OTR/L