A NOTICE OF PRIVACY PRACTICES

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

Our Duties:
We are required by law to maintain the privacy of your medical information and to provide you with notice of our legal duties and privacy practices. We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change those terms and any changes made will be effective for all medical information we maintain. A copy of a revised notice will be available at our offices , from our Privacy Officer by calling (408) 354.2223, or by writing to OPTM Sports and Physical Therapy, at 291 E. Main Street, Suite E, Los Gatos, CA 95030. You may also address questions regarding our privacy practices, your privacy rights, or requests for additional information regarding your privacy to this person.

Permitted Uses and Disclosures:
Federal Law allows use and disclosure of your medical information in the ordinary course of providing healthcare services to you. We have described some of these uses and disclosures in the following paragraphs:

• Treatment: We will provide to your other healthcare providers the minimal information they need to treat you. We may contact you before an appointment or talk to you about preparing for an appointment or a procedure. We will try to contact you at the phone numbers you have given us. If you are not available and your voice mail answers, we may leave a brief message to remind you of the place and time of your appointment . We may ask you to call us regarding specific medical information concerning your case. We will not leave your test results or your diagnosis on your voice mail machine.

• Payment: We will bill your insurance company and you directly or another person who may be responsible for payment of your account. We may need to contact you health plan to pre-authorize the exams, procedures or tests your doctor has ordered. Throughout this process we may have to release details of your medical information, if your health plan or other payer requires this information to make payment. If you do not want this information released to your payer, then you must pay your bill in full at the time of service and inform us not to bill anyone else.

• Health Care Operations: We often have to use specific patient information to conduct our normal business operations. We may have to look at the information in the doctor’s reports in order that we may fill out forms on your behalf. We may have to compare x-rays taken from other facilities with those in our file. We may use PHI to review our treatment and services and to evaluate the performance of our staff in caring for you.

Disclosures without Authorization
We may use and disclose medical information about you, without your specific authorization, as follows:

• Disclosures Required by Law: We may be required by federal, state, or local law to disclose your medical information.

• Public Health Activities: We may disclose your medical information to a public agency, such as the Food and Drug Administration (FDA), if you experience an adverse effect from any of the drugs, supplies, or equipment we use.

• Victims of Abuse, Neglect, or Domestic Violence: We may be required to disclose your medical information if we feel that you have been abused or neglected.

• Judicial and Administrative Proceedings: We may have to disclose your medical information if we receive a subpoena from a judge or administrative tribunal.

• Law Enforcement: We may have to disclose your medical information in conjunction with a criminal investigation by a federal or state law enforcement agency.

• Serious Threats to Health or Safety: We may be required to disclose your medical information if, in our opinion, doing so will help avert a serious threat to the public.

• Military Personnel: We may disclose your medical information to the appropriate command authorities.

• Worker’s Compensation: We may disclose your medical information to comply with laws regarding worker’s compensation.

Patient Rights
You have certain rights with respect to your medical information. While Federal law allows us to use and disclose your PHI for treatment, payment and health care operations, the law requires us to obtain your written consent to do so. Therefore, the first time you see one of our Physical Therapists or health care providers, we will ask you to sign a consent form allowing us to use and disclose you personal information in conjunction with your treatment, payment for treatment and our healthcare operations.

Requesting Restrictions: You may ask us to limit our use or disclosure of your protected health information. We are not required to agree to your request, but if we agree to it, we will abide by your request except as required by law, in emergencies, or when the information is necessary to treat you. Your request must: 1) be in writing, 2) describe the information that you want restricted, 3) state if the restriction is to limit our use or disclosure, and 4) state to whom the restriction applies. You may revoke your restriction at any time by contacting our Privacy Officer as noted on the first page. We may ask to reschedule your exam while we consider your request.

Confidential Communications: You may ask that we communicate with you in a particular way, or at a certain location to maintain your confidentiality. Your request must be in writing. It must tell us how you intend to satisfy your financial responsibility, and specify an alternate way that we can contact you confidentially. You do not have to give a reason for your request. You may revoke your request at any time by contacting our Privacy. We may ask to reschedule your exam while we consider your request.

Inspect and Copy: You may request access to inspect and copy your medical information maintained in our records, including billing records. Your request must be in writing. We will act on your request for inspections within 5 working days after we get the request. We will act on your request for copies within 15 days after we get the request. If we must deny your request, we will send you a written denial. If this happens, you may request a review of the denial. We hire an independent copy company to copy records for us. That company will send you a bill for the copies. If you want to know the charges in advance, you may request it. The copy service charges are based on state guidelines. If you have a dispute over the bill for copying you will need to dispute it with the copy service. The copies may be picked up in one of our offices at your request, or they may be mailed to you.

Amendment: You may ask us to amend your health information if you believe that it is incorrect or incomplete. Your request must be in writing and must include a reason to support the amendment. Your request may be denied if we believe that the information is complete and accurate, if the information is not part of the medical information that you would be permitted to inspect or copy, or if we did not create the information. You also have the option of submitting your own amendment. This amendment must be in writing and cannot be longer than 250 words per item that you are trying to correct. We will then include this amendment when we release the records in question.

Accounting of Disclosures: You may request a list of non-routine disclosures that we have made of your medical information. This does not include disclosures we make for your treatment, to seek payment for our services, or for our normal business operations or for those you authorize in writing. You may request an accounting for dates of service not prior to April 14, 2003. Your first request within a 12-month period is free, but we may charge for additional lists within the same 12-month period.

File a Complaint: If you believe that we have violated your privacy rights, you may file a complaint directly with our Privacy Officer using the contact information. You may also file a complaint with the Secretary of the Department of Health and Human Services. We will not penalize you for complaining.

Patient Authorizations for Certain Disclosures
We will request your written authorization for uses and disclosures of your medical information that we did not identify in this notice or for those not otherwise permitted by law. These disclosures may include your requests to provide exam results to your attorney, for exams related to life insurance or disability insurance applications or for pre-employment physicals. You may revoke your authorization in writing at any time by contacting our Privacy Officer. You may request a copy of your authorization at any time.