Privacy Notice

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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.

In the course of your care as a patient at Sarasota Center for Physical Medicine, LLC, we may use or disclose personal and health-related information about you in the following ways:

• Your personal health information, including your clinical records, may be disclosed to another healthcare provider or hospital if it is necessary to refer you for further diagnosis, assessment, or treatment.
• Your healthcare records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are, or may be, responsible for the payment of your services.
• Your name, physical address, phone number, email address, and healthcare records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health-related information that may be of interest to you.

If you are not home to receive an appointment reminder, a message may be left on your answering machine or cellular voicemail. Furthermore, you have the right to inspect or obtain a copy of the information we will use for these purposes. You also have the right to refuse to provide authorization for this office to contact you regarding these matters. If you do not provide us with this authorization it will not affect the care provided to you or the reimbursement avenues associated with your care.

Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in the following circumstances:

• If we are providing healthcare to you based on the orders of another healthcare provider.
• If we provide healthcare services to you in an emergency.
• If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so.
• If there are substantial barriers to communication with you, but in our professional judgment we believe that you minted for us to provide care.
• If we are ordered by the courts or another appropriate agency.

Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization.

We normally provide information about your health to you in person at the time you receive physical medicine care from us. We may also mail information to you regarding your healthcare or about the status of your account, or through an email address you provided on your intake form. Additionally, we may provide appointment reminders via these methods as well, including phone and/or text messaging. If you would like to receive this information at an address other than your home or if you would like the information in a different form, please advise us in writing to your preferences.

You have a right to inspect and/or copy your health information for seven years from the date that the record was created. In addition, you have the right to request an amendment to your health information. Requests to inspect, copy, or amend our health-related information should be provided to us in writing.

We are required by state and federal law to maintain the privacy of your patient file and protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information.

We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. Any changes made to this privacy notice will be updated and reflected on the Center for Physical Medicine Website (www.centerforphysicalmedicine.com/privacy-notice). Additionally, any changes made to our privacy notice will also apply to all of your information contained in our records.

Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.

If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to Dr. Erik Wenzel @ 941-921-4884 x105. You may also file a complaint with HHS at 1-850-245-4141. To report abuse, please call 1-800-962-2873.

This notice and any alterations or amendments made herein will expire seven (7) years after the date upon which the record was created. My signature acknowledges that I have received a copy of this notice.