HIPAA Notice of Privacy Policies: As required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 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. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by our organization, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bi Ils, to support the operation of the organization, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for equipment or supplies coverage may require that your relevant protected health information be disclosed to the health plan to obtain approval for coverage. Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of our organization. These activities include, but are not limited to, quality assessment activities, employee review activities, accreditation activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to accrediting agencies as part of an accreditation survey. We may also call you by name while you are at our facility. We may use or disclose your protected health information, as necessary, to contact you to check the status of your equipment.We may use or disclose your protected health information in the following situations without your authorization: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Criminal Activity, In mates, Military Activity, National Security, and Workers’ Compensation. Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization or Opportunity to Object, unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or this organization has taken an action in reliance on the use or disclosure indicated in the authorization. 

Your Rights: Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request just states the specific restriction requested and to whom you want the restriction to apply. Our organization is not required to agree to a restriction that you may request. If our organization believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, e.g., electronically. You may have the right to have our organization amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. W e are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information, if you have any questions concerning or objections to this form, please ask to speak with our President in person or by phone at 252-744-2426. 

Associated companies with whom we may do business, such as an answering service or delivery service, are given only enough information to provide the necessary service to you. No medical information is provided. We welcome your comments: Please feel free to call us if you have any questions about how we protect your privacy. Our goal is always to provide you with the highest quality services. 

Consent for Treatment: I authorize the staff at Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT) to undertake such treatment and procedures as deemed appropriate to improve my condition. It is recognized that the practice of medicine is not an exact science and, as such, no guarantees are made by the staff of Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT) as to the results of treatment or interventions performed. I am advised that I have the full right to a full explanation of any treatment or procedure utilized. I understand that I have the right to refuse treatment; but, in doing so, I also understand that the desired outcome of my treatment program may be affected. Persistent refusal to participate or cooperate in the recommended treatment program may result in my discharge from the program. 

Release of Information: Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT) may disclose all or any part of my records to any party or organization responsible for all or part of my therapy charges. Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT) may disclose all or part of my record to other health care providers including but not limited to, hospitals, physicians, and other payers. I further agree that Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT) may release all or any part of my record to any federal, state, or local government body when, in the opinion of Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT) such bodies may be liable for all or part of my charges in relation to my care and treatment pursuant to statute or rule. 

Financial Consent: I agree to be responsible for payment of all outpatient physical therapy charges which are not covered by insurance, attorney, workman’s comp or whichever is applicable to my case and when appropriate, to submit applications to federal, state, and county programs. I understand Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT) will bill me, my family, and/or other responsible parties for services provided. 

Photography Consent: I hereby grant to Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT) the unlimited right and permission to use in perpetuity my photograph, video footage, actions, and/or testimonial, either alone or accompanied by other material, in any manner and in any media, throughout the world, at anytime, for any and all lawful purposes, including but not limited to, all promotion, marketing, advertising and publicizing of Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT)’s services, or Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT)’s clients’ products or services. Personal Property: It is understood that Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT) shall not be liable for loss or damage to any personal items brought to Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT) during your course of treatment. 

Assignment of Insurance Billing: I and/or the responsible party voluntarily assign Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT) and its independent contracting providers the right to pursue their respective claims for reimbursement from any insurance policy or policies providing coverage for services provided. 

Cancellation Policy: Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT) is founded upon, one- on-one, quality care. We provide an empowering environment with individualized care to achieve optimal healing and functional recovery for our patients. In keeping with our mission we ask that our patient be adherent to their scheduled physical therapy appointments. 

If you should have to cancel an appointment, we kindly request at least 24 business hours notice. 

For patients who do not W provide at least 24 business hours advance notice, if we feel it is necessary we will charge you a $35 fee. 

Repeated cancellations and/or not showing up to appointments do not align with the Residential Therapy Solutions (DBA Premier Performance Physical Therapy or 3PT) mission. Please be advised if you cancel and/or no show for 3 physical therapy appointments your therapist may discharge you from care and send your referring provider a note regarding your non- adherence to your therapy plan of care. 

Release of Liability: It is expressly agreed that all exercises and treatments and use of all facilities and equipment shall be undertaken at the patients/ members own risk, and the member represents that he/she is physically able to understand and all physical exercises and treatments provided Premier Performance Physical Therapy, 3PT, Residential Therapy Solutions or any of its agents, employees, and/or therapists, shall not be liable for any claims, demands, injuries, damages, actions, or causes of action whatsoever to the member and/or patient arising out of, or connected with the use of any of the services, and/or facilities. Patient and/or member does hereby expressly forever release and discharge Premier Performance Physical Therapy, 3PT, Residential Therapy Solutions or any of its agents, employees, and/or therapists and/or all of their affiliated companies from all such claims, demands, injuries, damages, actions or causes of section, and from all facts of active or passive negligence on the part of such companies, corporations, clubs, studios, their servants, agents, or employees I do hereby agree and give my consent the Premier Performance Physical Therapy, 3PT, Residential Therapy Solutions and any of its agents, employees, and/or therapists to furnish care and treatment that is considered necessary and proper in the diagnosing or treating of my physical condition. 

I understand that I retain the right to revoke this consent by notifying the practice in writing at any time. I have read, had the opportunity to ask questions and fully understand the policies.