SUMMARY OF OUR NOTICE OF PRIVACY PRACTICES

  • Performance Physical Therapy of Connecticut, LLC
  • Performance Physical Therapy of Hamden, LLC
  • Performance Physical Therapy of New York, PLLC
  • Performance Physical Therapy of Stamford LLC
  • Performance Physical Therapy of Westport, LLC

 

Effective Date: January 1st, 2013

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
Please review the full Notice of Privacy Practices (NPP), which is attached. If you have any questions about
this notice, please contact, Michael Cook, privacy officer at (203) 422-0679.

WHO WILL FOLLOW THIS NOTICE:

  • Performance Physical Therapy of Connecticut, LLC
  • Performance Physical Therapy of Hamden, LLC
  • Performance Physical Therapy of New York, PLLC
  • Performance Physical Therapy of Stamford LLC
  • Performance Physical Therapy of Westport, LLC

All these entities, sites, and locations follow the terms of this notice. In addition, these entities, sites, and
locations may share health information with each other for treatment, payment, or health care operations
purposes described in this notice.

OUR PLEDGE REGARDING HEALTH INFORMATION:
We understand that health information about you and your health care is personal. We are committed to
protecting health information about you. We create a record of the care and services you receive from us.
We need this record to provide you with quality care and to comply with certain legal requirements. This
notice applies to all of the records of your care generated by this health care practice, whether made by
your personal physical therapist or others working in this office. This notice will tell you about the ways in
which we may use and disclose health information about you. We also describe your rights to the health
information we keep about you, and describe certain obligations we have regarding the use and disclosure
of your health information.

We are required by law to:
• Make sure that health information that identifies you is kept private;
• Give you this notice of our legal duties and privacy practices with respect to health information
about you; and
• Follow the terms of the notice that are currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU.
The following categories describe different ways that we use and disclose health information. By coming
for care, you give us the right to use your information for treatment, to get reimbursed for your care, and to
operate our organization. There are also various other ways in which we may use or disclose your
information:
• Appointment Reminders
• Health-Related Services and Treatment Alternatives
• To Allow Oversight of the Quality of the Healthcare We Provide
• To Allow Workers' Compensation Claims
• As Required by Subpoena in Lawsuits and Disputes
• Various Uses as Required by Law or to Avert a Serious Threat to Health or SafetyThe full details for all these uses are contained in the full NPP.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU.
You have the following rights regarding health information we maintain about you:
• Right to Inspect and Copy
• Right to Amend
• Right to an Accounting of Disclosures
• Right to Request Restrictions
• Right to Request Confidential Communications
• Right to a Paper Copy of This Notice
Information on how to exercise these rights can be seen in the NPP or can be obtained from Michael Cook,
privacy officer at (203) 422-0679.

CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice
effective for health information we already have about you as well as any information we receive in the
future. We will post a copy of the current notice in our facility. The notice will contain on the first page, in
the top right-hand corner, the effective date. In addition, each time you register for treatment or health
care services,we will offer you a copy of the current notice in effect.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary
of the Department of Health and Human Services. To file a complaint with us, please contact Michael
Cook, Privacy Officer at (203) 422-0679. All complaints must be submitted in writing. You will not be
penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this notice or the laws that apply to us will
be made only with your written permission. If you provide us permission to use or disclose health
information about you, you may revoke that permission, in writing, at any time. If you revoke your
permission, we will no longer use or disclose health information about you for the reasons covered by your
written authorization. You understand that we are unable to take back any disclosures we have already
made with your permission, and that we are required to retain our records of the care that we provided to
you.