Brookside Physical Therapy
Effective Date: June 1, 2013

If you have any questions about this notice, please contact Sarah Andres, office supervisor, at (303) 428-4646.

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 doctor 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

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 is currently in effect.

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain
what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use
and disclose information will fall within one of the categories.

For Treatment. We may use health information about you to provide you with health care treatment or services. We may disclose health information
about you to doctors, nurses, technicians, health students, or other personnel who are involved in taking care of you. They may work at our offices, at the
hospital if you are hospitalized under our supervision, or at another doctor’s office, lab, pharmacy, or other health care provider to whom we may refer
you for consultation, to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes. For example, a doctor treating you
for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the
dietitian at the hospital if you have diabetes so that we can arrange for appropriate meals. We may also disclose health information about you to an
entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
© 2001-2002 On File – p. 1of 7

For Payment: We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and
payment collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about your office
visit so your health plan will pay us or reimburse you for the visit. 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.

For Health Care Operations: We may use and disclose health information about you for operations of our health care practice. These uses and
disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use health information to
review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many
patients to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare
how we are doing with others and to see where we can make improvements. We may remove information that identifies you from this set of health
information so others may use it to study health care delivery without learning who our specific patients are.

Health-Related Services and Treatment Alternatives: We may use and disclose health information to tell you about health-related services or
recommend possible treatment options or alternatives that may be of interest to you. Please let us know if you do not wish us to send you this
information, or if you wish to have us use a different address to send this information to you.

As Required By Law. We will disclose health information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose health information about you when necessary to prevent a serious threat to your
health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the

Military and Veterans. If you are a member of the armed forces or separated/discharged from military services, we may release health information about
you as required by military command authorities or the Department of Veterans Affairs as may be applicable. We may also release health information
about foreign military personnel to the appropriate foreign military authorities.

Workers’ Compensation. We may release health information about you for workers’
compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose health information about you for public health activities. These activities generally include the following:
• to prevent or control disease, injury or disability;
• to report births and deaths;
• to report child abuse or neglect;
• to report reactions to medications or problems with products;
© 2001-2002 On File – p. 2 of 7

• 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. We will only make this
disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities
include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care
system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or
administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by
someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information

Law Enforcement. We may release health information if asked to do so by a law enforcement official:
• in reporting certain injuries, as required by law, gunshot wounds, burns, injuries
to perpetrators of crime;
• in response to a court order, subpoena, warrant, summons or similar process;
• to identify or locate a suspect, fugitive, material witness, or missing person:
– Name and address
– Date of birth or place of birth;
– Social security number;
– Blood type or rh factor;
– Type of injury;
– Date and time of treatment and/or death, if applicable; and
– A description of distinguishing physical characteristics.
• about the victim of a crime, if the victim agrees to disclosure or under certain
limited circumstances, we are unable to obtain the person’s agreement;
• about a death we believe may be the result of criminal conduct;
• about criminal conduct at our facility; and
• in emergency circumstances to report a crime; the location of the crime or
victims; or the identity, description, or location of the person who
committed the crime.

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

© 2001-2002 On File – p. 3 of 7
National Security and Intelligence Activities. We may release health information about you to authorized federal officials for intelligence,
counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose health information about you to authorized federal officials so they may provide
protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Inmates. If you are an inmate of a correctional institution or under the custody of a law
enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be
necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety
and security of the correctional institution.

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 health information that may be used to make decisions about your care. Usually, this includes health and billing

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to Sarah Andres, office
supervisor. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with
your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request
that the denial be reviewed. Another licensed health care professional chosen by our practice will review your request and the denial. The person
conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend. If you feel that health information we have about you is incorrect or
incomplete, you may ask us to amend the information. You have the right to request an
amendment for as long as we keep the information. To request an amendment, your request must be made in writing, submitted to Sarah Andres, office
supervisor, and must be contained on one page of paper legibly handwritten or typed in at least 10 point font size. In addition, you must provide a
reason that supports your request for an amendment.

We may deny your request for an amendment if it 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 amend information that:
• was not created by us, unless the person or entity that created the information
is no longer available to make the amendment;
• is not part of the health information kept by or for our practice;
• is not part of the information which you would be permitted to inspect and copy;
• is accurate and complete.
© 2001-2002 On File – p. 4 of 7
Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting of Disclosures. You have the right to request a list accounting for any disclosures of your health information we have made,
except for uses and disclosures for treatment, payment, and health care operations, as previously described.

To request this list of disclosures, you must submit your request in writing to Sarah Andres, office supervisor. Your request must state a time period which
may not be longer than six years and may not include dates before April 14, 2003. 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. We will mail you a list of disclosures in
paper form within 30 days of your request, or notify you if we are unable to supply the list within that time period and by what date we can supply the list;
but this date will not exceed a total of 60 days from the date you made the request.

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 your care, such as a family member or friend. For example, you could ask that we restrict a specified
nurse from use of your information, or that we not disclose information to your spouse about a surgery you had.

We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the
care we may provide you. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To
request a restriction, you must make your request in writing to Sarah Andres, office supervisor. In your request, you must tell
us what information you want to limit and to whom you want the limits to apply; for example, use of any information by a specified nurse, or disclosure of
specified surgery to your spouse.

Right to Request Confidential Communications. You have the right to request that we communicate with you about health 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 to a post office box. To request confidential communications,
you must make your request in writing to Sarah Andres, office supervisor. 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 obtain a paper copy of this notice at any time. To obtain a copy, please request it from
Sarah Andres, office supervisor. You may also obtain a copy of this notice either from our website, www.brooksidept.com, or by requesting a copy of this
notice be sent through electronic mail to sandres@brooksidept.com. If we know that the electronic message has failed to be delivered, a paper copy of
the notice will be provided. Even if you have received a notice electronically, you still retain the right to receive a paper copy upon request.
© 2001-2002 On File – p. 5 of 7
If the first service delivery is delivered electronically, other than by telephone, we provide electronic notice in the same medium, automatically and
contemporaneously in response to a first request for service.

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.

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, contact Sarah Andres, office supervisor. All complaints must be submitted in writing. You will not be penalized for
filing a complaint.

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.

Acknowledgement of Receipt of this Notice
We will request that you sign a separate form or notice acknowledging you have received a copy of this notice. If you choose, or are not able to sign, a
staff member will sign their name, date. This acknowledgement will be filed with your records.