Notice of Privacy Practices


I. We have a legal duty to safeguard your protected health information (PHI).

We are legally required to protect the privacy of your health information. We call this information “protected health information,” or “PHI” for short, and it includes information that can be used to identify you that we’ve created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of this health care. We must provide you with this notice about our privacy practices that explains how, when, and why we use and disclose your PHI. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure. We must notify you if there is a breach of your unsecured protected health information.

We are legally required to follow the privacy practices that are described in this notice. However, we reserve the right to change the terms of this notice and our privacy policies at any time. Any changes will apply to the PHI we already have. You can request an up to date copy of this notice from our office at any time.

II. How we may use and disclose your protected health information.

A. We use and disclose health information for many different reasons. For some of these uses or disclosures, we do not need your prior authorization. Below, we describe the different categories of our uses and disclosures and give you some examples of each category.

B. We may use and disclose your PHI without your authorization for the following reasons:

  1. For treatment. We may use and disclose your PHI to all health care personnel who provide you with health care services or are involved in your care.
  2. For payment. To obtain payment for treatment, we may use and disclose your PHI in order to bill and collect payment for the treatment and  services provided to you. We may also provide your PHI to our business  associates, such as billing companies, claims processing companies, and others that process our health care claims.
  3. For health care operations. We may use and disclose your PHI in order to operate this medical practice. For example, we may use your PHI in order to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided health care services to you. We may also provide your PHI to our accountants, attorneys, consultants, and others in order to make sure we’re complying with the laws that affect us.
  4. When a disclosure is required by federal, state, or local law, judicial or administrative proceedings, or law enforcement. For example, we make disclosures when a law requires that we report information to government agencies and law enforcement personnel about victims of abuse, neglect, or domestic violence; or when ordered in a judicial or administrative proceeding.
  5. For public health activities. For example, we report information about births, deaths, and various diseases, to government officials in charge of collecting that information, and we provide coroners, medical examiners, and funeral directors necessary information relating to an individual’s death.
  6. For health oversight activities. For example, we will provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization.
  7. For research purposes . In certain circumstances, we may provide PHI in order to conduct medical research.
  8. To avoid harm. In order to avoid a serious threat to the health or safety of a person or the public, we may provide PHI to law enforcement personnel or persons able to prevent or lessen such harm.
  9. For specific government functions. We may disclose PHI of military personnel and veterans in certain situations. And we may disclose PHI for national security purposes, such as protecting the president of the United States or conducting intelligence operations.
  10. For workers’ compensation purposes. We may provide PHI in order to comply with workers’ compensation laws.
  11. Appointment reminders and health-related benefits or services. We may use PHI to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits we offer.

C. One use and disclosure requires you to have the opportunity to object.

  1. Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in  your care or the payment for your health care unless you object in whole or in part. If you are unable to agree or object to the disclosure, we may disclose the information as necessary if we determine that it is in your best interest based on our professional judgment.

D. All other uses and disclosures require your prior written authorization.

  1. Most uses and disclosures for marketing purposes require your authorization.
  2. Disclosures that constitute a sale of PHI require your authorization.
  3. In any other situation not described in this notice, we will ask for your written authorization before using or disclosing any of your PHI.
  4. If you choose to sign an authorization to disclose your PHI, you can later  revoke that authorization in writing to stop any future uses and disclosures (to the extent that we have not taken any action relying on the authorization).

III. What rights you have regarding your PHI.

You have the following rights with respect to your PHI:

  1. The right to request limits on uses and disclosures of your PHI. You have the right to ask that we limit how we use and disclose your PHI. We will consider your request but are not legally required to accept it, except that we must agree if you ask us not to disclose PHI to your health plan for the purposes of payment or health care operations when the PHI is related to a health care item or service you have paid for out of pocket in full. If we accept your request, we will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that we are legally required or allowed to make.
  2. The right to choose how we send PHI to you . You have the right to ask that we send information to you to an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, certified mail instead of regular mail). We must agree to your request so long as we can easily provide it in the format you requested.
  3. The right to see and get copies of your PHI. In most cases, you have the right to look at or get copies of your PHI that we have, but you must make the request in writing. If we do not have your PHI but we know who does, we will tell you how to get it. We will respond to you within 30 days after receiving your written request. In certain situations, we may deny your request. If we do, we will tell  you, in writing or by phone, our reasons for the denial and explain your right to have the denial reviewed.
  4. The right to get a list of the disclosures we have made. You have the right to get a list of instances in which we have disclosed your PHI. The list will not include uses or disclosures that you have already consented to, such as those made for treatment, payment, or healthcare operations, directly to you, to your family, or in our facility directory. The list also will not include uses and disclosures made for national security purposes, to corrections or law enforcement personnel, or those made earlier than 6 years before your request. We will respond within 60 days of receiving your request. The list we will give you will include disclosures made in the last 2 years unless you request a shorter time. The list will include the date of the disclosure, to whom PHI was disclosed  (including their address if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you at no charge.
  5. The right to correct or update your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing, you have the right to request that we correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. We will respond within 60 days of receiving your request. We may deny your request in writing if the PHI is (1) correct and complete, (2) not created by us, (3) not allowed to be disclosed, or (4) not part of our records. Our written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you do not file one, you have the right to request that your request and our denial be attached to all future disclosures of your PHI. If we approve your request, we will make the change to your PHI, tell you that we have done it, and tell others that need to know about the change to your PHI.
  6. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

IV. How to complain about our privacy practices. 

If you think that we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may file a complaint with our office. You also may send a written complaint to the Secretary of the Department of Health and Human Services. We will take no retaliatory action against you if you file a complaint about our privacy practices.

V. Effective Date. 

This Notice of Privacy Practices is effective as of November 11, 2019.

The Health Insurance Portability and Accountability Act (HIPAA) requires all health care
providers inform patients about how their medical information may be used and disclosed
and how patients can get access to that information. The purpose of this form is to
document that you have received such information.
Please fill out, date, and sign this form after you have had a chance to review, understand,
and/or ask questions about your rights to privacy and confidentiality.
Patient Full Name: ____________________________________________ (please print)
Patient Address:
__ / __ / ____ (mm/dd/year)
I hereby acknowledge that I have received and reviewed a copy of Advanced Musculoskeletal
Medicine Consultants, Inc. Notice of Privacy Practices.
Signature: __________________________________________
Patient/Parent or Guardian Signature (please specify)
Full Name (please print)