HIPAA Form

Points North Physical Therapy LLC  – 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.

Points North Physical Therapy LLC is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Click here for a printable HIPAA Form. If printing the HIPAA form, please bring it with you to your first appointment or fax it to us at (802) 264-8519.

Disclosure of Your Health Care Information

Treatment
We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations.

Payment
We may disclose your health information to your insurance provider for the purpose of payment or health care operations.

Workers’ Compensation
We may disclose your health information as necessary to comply with State Workers’ Compensation Laws.

Emergencies
We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care in the event of an emergency.

Public Health
As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.

Judicial and Administrative Proceedings
We may disclose your health information in the course of any administrative or judicial proceeding.

Public Safety
It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.

Change of Ownership
In the event that Points North Physical Therapy LLC is sold or merged with another organization, your health information/record will become the property of the new owner.

  • Date Format: MM slash DD slash YYYY
  • I have read the Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide Points North Physical Therapy LLC with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment,payment and health care operations as described in the Privacy Notice.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

 

Where to find us

Points North Physical Therapy
435 Points North Rd.
Stowe, VT 05672

Get Directions

Phone: (203) 260-0215
Fax: (802) 264-8519

Email: info@pointsnorthphysicaltherapy.com