Patients/Clients frequently request that we communicate with them by phone, voicemail, email, or text. 

Play On Physical Therapy, LLC respects your right to confidential communications about your protected health information (PHI) as well as your right to direct how those communications occur. 

Since email and texting can be inherently insecure as a method of communication, we will only communicate with you by email or text with your written consent at the email address or phone number you provide to us below. Please be aware that if you have an email account through your employer, your employer may have access to your email. Email, voicemail, and text communications may be filed into your medical record. 

When you consent to communicating with us by email or text you are consenting to email and texting communications that may not be encrypted. Play On Physical Therapy cannot guarantee, but will use reasonable means to maintain, the security and confidentiality of the messages we send. As well voicemail or answering machine messages may be intercepted by others. Therefore, you are agreeing to accept the risk that your protected health information may be intercepted by persons not authorized to receive such information when you consent to communicating with us through phone, voicemail, email, or text. 

Play On Physical Therapy, LLC will not be responsible for any privacy or security breaches that may occur through voicemail, email, or text communications that you have consented to. You may choose to limit the type of voicemail, email, or text communication you have with us if you wish to limit your risk of exposing your protected health information to unauthorized persons. Please indicate below what types of correspondence you consent to receive by email or text. 

 IN A MEDICAL EMERGENCY, DO NOT USE ELECTRONIC MESSAGING, CALL 911. 

Urgent messages or needs should be relayed to us by using regular telephone communication. 

Expiration and Withdrawal of Consent: 

Unless you earlier withdraw your consent, this consent will expire upon the end of your treatment relationship with Play on Physical Therapy. You may choose to stop participating in email/text/voicemail communications at any time by informing Play On Physical Therapy in writing as described herein. To withdraw consent and stop participating in email/text/voicemail communications, please contact the Play On Physical Therapy Privacy Officer as described in the Notice of Privacy Practices. 

Patient Acknowledgement and Agreement: 

I have read and fully understand this consent form. I understand the risks associated with the use of phone, voicemail, email, and text communications between Play On Physical Therapy and me, and I consent to the conditions and instructions outlined, as well as any other instructions that Play On Physical Therapy may impose to communicate with me by these methods. I understand that Play On Physical Therapy will communicate to those telephone number(s) and email address(es) identified herein. 

Release: 

In consideration of Play On Physical Therapy’s services and my request to receive communications as described herein, I hereby release Play On Physical Therapy from any and all claims, causes of action, lawsuits, injuries, damages, losses, liabilities or other harms resulting from or relating to the calls or messages, including but not limited to any claims, causes of action, or lawsuits based on any asserted violations of the law (including without limitation the Telephone Consumer Protection Act, the Truth in Caller ID Act, the CAN-SPAM Act, the Fair Debt Collection Practices Act, the Fair Credit Reporting Act, the Health Insurance Portability and Accountability Act, any similar state and local acts or statutes, and any federal or state tort or consumer protection laws). 

By signing below, Patient consents to communication with Play On Physical Therapy as described herein. 

During the physical therapy evaluation for the problems you have reported, an assessment of your low back, hips, and pelvic girdle will be performed by a physical therapist in order to identify any musculoskeletal problems. This may include an evaluation of your pelvic floor muscles for strength, resting tone (tightness), and coordination (contract/relax). The findings will be discussed with you, and you will work with your physical therapist to develop a treatment plan that is appropriate for YOU. Your evaluation MAY include an internal assessment of the pelvic floor muscles, which could be completed vaginally (females) or rectally (males & females). A biofeedback assessment of your pelvic floor muscles may also be performed and may include internal or external sensors. Your physical therapist will discuss this option and receive your consent BEFORE initiating this exam. You absolutely can say NO, and your physical therapist can assess and treat the pelvic floor muscles externally (from the outside) if needed. 

If you are pregnant, have an infection of any kind, have an IUD or other implants, have a sexually communicable disease, are less than 6 weeks postpartum or post-surgery, have severe pelvic pain, sensitivity to lubricant, vaginal creams or latex, please inform the therapist prior to the pelvic floor assessment. The assessment of the pelvic floor muscles may result in soreness or discomfort temporarily. If this occurs, please discuss your symptoms with your physical therapist. Evaluation and treatment may result in emotional distress, reproduction of pain, or discomfort, and if you are unable to tolerate the evaluation or treatment you have the right to terminate the therapy session at any time. 

We realize that many patients may be apprehensive because of the private nature of the condition and the examination. Please ask as many questions as you need to increase your comfort and understanding of your evaluation, its findings, and treatment. Please discuss any concerns or hesitation that you may have with your physical therapist. 

In the case of a pelvic evaluation being performed on a minor, Play On Physical Therapy will require the presence of a parent or legal guardian as well as a Play On Physical Therapy staff member/witness (to be agreed upon by the parent or legal guardian) being present during the examination. 

I have read and understand the Informed Consent for Pelvic Floor Muscle Evaluation, and consent to the evaluation and treatment, unless otherwise noted below. I have informed my therapist of any condition that would limit my ability to have an evaluation or be treated. 

NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLEDGEMENT 

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. 

I have received this practice’s HIPAA Notice of Privacy Practices (NPP). This NPP provides a detailed summary of the uses and disclosures of my protected health information that made be made by this practice, my individual rights, how I may utilize those rights, and the practice’s legal duties with respect to my information. 

I understand this information can be used to conduct, plan and direct my treatment including subsequent follow-ups with the healthcare providers who are either directly or indirectly involved with my treatment. 

This can also be shared with third party payers to obtain reimbursement. 

I understand that this practice reserves the right to change the terms of its NPP, and to make changes regarding all protected health information controlled by this practice. I understand I can obtain this practice’s current NPP upon request. 

I have been given the right to review such NPP prior to signing this consent. I understand that I may request in writing that this practice restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that this practice is not required to agree to my requested restrictions, but if the organization does agree, then it is bound to abide by such restrictions. 

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. 

If you have any questions about this notice, please contact our Privacy Officer: 

Play On Physical Therapy 
Attn: Privacy Officer 
[ADDRESS] 
[TELEPHONE] 
[EMAIL] 

This notice describes the procedures and practices that Play On Physical Therapy and its professional, support, and administrative staff follow to protect the privacy of your health information. 

For more information, visit https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html and https://www.hhs.gov/hipaa/for-individuals/notice-privacy-practices/index.html. 

Your Health Information 

This notice applies to the information and records we have about your health, health status, and the health care and services you receive at this office. Your health information may include information created and received by this office, it may be in the form of written or electronic records, images or spoken words, and it may include information about your health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, related billing activity, and similar types of health-related information. 

We are required by law to maintain the privacy of your health information and to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information. We are required to abide by the terms of this notice, and to notify you of a breach of your unsecured health information. 

How we may use and disclose health information about you 

We may use and disclose health information for the following purposes: 

For Treatment: We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, office staff, or other personnel who are involved in taking care of you and your health. 

For example, the doctor who referred you for physical therapy may be treating you for a medical or orthopedic condition, and we may need to know about that and any other health problems that could complicate your treatment. We may use your medical history to decide what treatment is best for you. We will consult with your doctor and send reports about your treatment to the doctor. We do this to provide the most appropriate care for you. 

Different personnel in our office may share information about you and disclose information to people who do not work in our office in order to coordinate your care, such as telephoning your doctor and getting needed information. Family members and other health care providers may be part of your physical therapy outside this office and that may require us to provide information about you. 

Lawsuits and Disputes: We may disclose your health information in response to a court or administrative order, subpoena, discovery request, or other legal process, subject to certain restrictions. 

Law Enforcement: We may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons, or similar process subject to all applicable legal requirements. 

Coroners, Medical Examiners, and Funeral Directors: We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may release health information to funeral directors as necessary for them to carry out their duties. 

Information Not Personally Identifiable: We may use or disclose health information about you in a way that does not personally identify you or reveal who you are. 

Family and Friends: We may disclose health information about you to your family members, friends, or others you have involved in your care or payment if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgment, that you would not object. For example, we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you into the room during treatment or while treatment is discussed. In future visits, if you do not bring your spouse this assumption would not continue. 

In situations where you are not capable of giving consent (due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person’s involvement in your care. 

Personal Representative: If you have a personal representative who has authority to make health care decisions on your behalf, such as a parent or guardian, we may disclose your health information to such a personal representative. 

Other uses and disclosures pursuant to your signed authorization 

We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization. We will not sell your health information, use or disclose any psychotherapy notes about you, or use or disclose your health information for marketing purposes without your Authorization unless otherwise permitted under federal law. If you sign an Authorization for us to use or disclose health information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission. 

Your rights regarding your health information 

You have the following rights regarding health information we maintain about you: 

Right to Inspect and Copy: You have the right to inspect and copy your health information, such as medical and billing records, that we keep and use to make decisions about your care. You must submit a written request to our Privacy Officer (at the address listed at the top of this Notice) in order to inspect and/or copy records of your health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other associated supplies. 

We may deny your request to inspect and/or copy records in certain limited circumstances. If you are denied copies of or access to, health information that we keep about you, you may ask that our denial be reviewed. If the law gives you a right to have our denial reviewed, we will select a licensed health care professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review. 

Right to Correct: If you believe health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request a correction as long as the information is kept by this office. 

To request a correction, complete and submit a MEDICAL RECORD AMENDMENT/CORRECTION FORM to our Privacy Officer. We will provide you with one of these forms at your request. 

We may deny your request for an amendment if your request is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to correct information that: 

We did not create, unless the person or entity that created the information is no longer available to make the correction: 

• Is not part of the health information that we keep 
• You would not be permitted to inspect and copy 
• Is accurate and complete 

Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a record of the disclosures we made of medical information about you for purposes other than treatment, payment, health care operations, and a limited number of special circumstances involving national security, correctional institutions, and law enforcement. The record may also exclude any disclosures we have made based on your written authorization. 

To obtain this accounting, you must submit your request in writing to our Privacy Officer. It must state the time period for which you want an accounting. The time period may not be longer than six years. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time, before any costs are incurred. 

Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for it, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. 

If you or someone on your behalf pays for a service in full and you request that we not disclose information about the service to your health plan for purposes of payment of health care operations, we are required to agree to your request unless the disclosure is required by law. For all other types of restriction requests, we are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or we are required by law to use or disclose the information. 

To request restrictions on the use/disclosure or medical information and/or confidential communication, you may contact our Privacy Officer. 

Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail or e-mail. To request confidential communications, you may contact our Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. 

Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. 

To obtain such a copy, contact the Privacy Officer. 

Changes to this notice 

We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future. We will post the current notice or a summary of the current notice in the office with its effective date in the top right-hand corner. You are entitled to a copy of the notice currently in effect. 

Complaints 

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services, Office for Civil Rights by calling 1-877-696-6775, by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, or by visiting www.hhs.gov/ocr/privacy/hipaa/complaints. To file a complaint with our office, contact our Privacy Officer (at the address listed at the top of this Notice). You will not be penalized for filing a complaint.