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