HIPAA NOTICE OF HEALTH INFORMATION PRIVACY POLICY

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
OUR PLEDGE AND LEGAL DUTY:
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 05/2015 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact Leaps And Bounds Therapy, LLC. at 312-480-7433.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe the different ways that we use and disclose health information.
Treatment: Your health information may be used by staff members or disclosed to other health care providers for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment.

Payment: We may use and disclose your health information to obtain payment for services we provide to you. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

Healthcare Operations: Your health information may be used as necessary to support the day-to-day operations and management of Leaps And Bounds Therapy, LLC For example, quality assessment and improvement activities, reviewing the competence or qualifications of the healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: Disclosure of your health information or its use for any purpose other than for those listed requires
your specific written authorization. If you give us an authorization, you may revoke it in writing at any time. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.

Family or Friends Involved in Your Care: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Law Enforcement: Your health information may be disclosed to law enforcement agencies without your permission, to
support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting.

Public Health Reporting: Your health information may be disclosed to public health agencies as required by law. For example: to prevent or control disease, injury or disability; to report child abuse or neglect; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify person or organization required to receive information on FDA-regulated products; to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voice mail messages, postcards, or letters).

INDIVIDUAL RIGHTS:
You have certain rights under the federal privacy standards. These include:
• The right to request restrictions on the use and disclosure of your protected health information
• The right to receive confidential communications concerning your medical condition and treatment
• The right to inspect and copy your protected health information. If you request a copy we reserve a right to charge a fee for copies, mailing and administration expense.
• The right to amend or submit corrections to your protected health information
• The right to receive an accounting of how and to whom your protected health information has been disclosed
• The right to receive a printed copy of this notice
• As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing.

Privacy and Security: In order to maintain the confidentiality and privacy of our clients we will maintain all PHI collected from our clients or generated in our office in a secured/locked office in which only employees of Leaps And Bounds Therapy, LLC have access. This information will be stored for a total of 7 years following discharge. At the conclusion of the 7th year all documentation will be destroyed via shredding. As previously stated this information may not be disclosed to any outside parties without your written consent. For further information please consult our privacy officer and the address listed below.

QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact our designated privacy officer, Aneri D. Bhansali.

If you believe your privacy rights have been violated, you may file a written complaint to the address given below. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C. in writing within 180 days of a violation of your rights. We will not penalize you for filing a complaint.

Privacy Officer: Aneri Bhansali PT, DPT
Phone: 312-480-7433
Address: Leaps And Bounds Therapy, LLC, 455 Butler Drive, Lake Forest, IL 60045

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE

I have received a copy of this office’s Privacy Practices.

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By submitting this form and completing the name field as a digital signature, I attest the the information provided is truthful.
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