I hereby give my consent to Cannizzaro Physical Therapy, PLC to send physical therapy notes, and to discuss information regarding myself or my child, to my primary and referring physicians, my authorized representative, my case manager and my insurance companies. I also understand that my health information may be used to carry out my care and treatment, to obtain payment, and for this organization's health care operations.

As a patient/client, you have the right to request that Cannizzaro Physical Therapy, PLC restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement. We require that this request be put in writing.

A more complete description of uses and disclosures is in Pelvic Health's 'Notice of Health Information Packet' which is on page three of this document.

I further authorize Cannizzaro Physical Therapy, PLC to obtain medical records, make phone contact, or obtain other information related only to my treatment plan. Fax transmissions may be used.

A more complete description of uses and disclosures is in Pelvic Health's 'Notice of Health Information Packet'. A copy of this form follows. Please read the copy of Pelvic Health's 'Notice of Health Information Practices'.

Notice of Health Information Practices

This notice describes how information about you may be used and disclosed and how you can obtain access to this information. Please review it carefully.

Your Health Information

Each time you visit your physical therapist your visit is recorded. This record may contain your symptoms, diagnoses, test results, and a treatment plan and notes. This information becomes part of your medical record and helps healthcare professionals plan your care and treatment. As a consumer of healthcare, it is important for you to understand what is in your medical record, who may have access to your record, and how information about you may be used for healthcare related and non-healthcare related purposes.

Pelvic Health is committed to safeguarding the confidentiality, security and integrity of your medical record. Additionally, Pelvic Health has drafted this notice to be in compliance with federal standards for safeguarding the privacy of protected healthcare information and to help you understand your rights and our responsibilities with respect to your medical record.

We reserve the right to revise or change this Notice at any time. If there is any significant change in Pelvic Health's privacy policies, this Notice will be changed and the new Notice will be available upon your request.

Your Rights

It is important to understand that a medical record is an important historical document. While the information in the record belongs to you, the physical record is the property of Pelvic Health. In this regard, you have the following rights:

• To inspect and receive a copy of your medical record;
• To correct information about you that may not be correct. For example, an incorrect birth date or a new address;
• To submit an addendum to your record;
• To obtain an accounting of disclosures of your record;
• To revoke (i.e. take back) your consent/authorization to use or disclose information in your record except to the extent that action has already been taken.
• To request communication with you in ways that safeguards the confidentiality of your healthcare information.
• To request a restriction on certain uses and disclosures of your health information. We are not required to agree to your request for restrictions if it is not feasible for us to comply with your request or if we believe that it will negatively impact our ability to care for you. These requests will be reviewed by the Privacy Officer on an individual basis.
• To receive a paper copy of this Notice of Information Practices.

Pelvic Health's Responsibilities:

As a healthcare organization, we will do the following:

• Provide your healthcare information to you, your authorized representative who you have designated to us in writing, attending consulting physicians, other healthcare providers who you designate, and to others to the extent necessary for Pelvic Health to carry out its lawful activities. Examples include sending copies of evaluations and progress notes to your physician(s) and including identifying information about you to your insurance company for reimbursement for services provided to you. Unless requested to do so by law or court order, Pelvic Health will not disclose your healthcare information to any others unless we have your informed written authorization.
• Provide your healthcare information to those parties who are responsible for paying your medical bills. This may include your insurance carrier and other third-party payers, including worker's compensation carriers and automotive insurers, if applicable.
• Make reasonable efforts to limit the information we release or request to the minimum necessary to accomplish the intended purpose.
• Provide information to business associates with whom we contract in order to provide you with healthcare services. To protect healthcare information we provide to business associates, we require all business associates to sign Agreements that set forth the safeguards that must be followed regarding the protection of patient records. Examples of business associates include medical record transcriptionists and equipment vendors.
• There are several circumstances where Pelvic Health is either permitted or required by state or regulation to disclose confidential healthcare information to others without your consent. These circumstances may include, but are not limited to the following:

1. To governmental authorities as required by statue (for example, we are required to report suspected child or elder abuse/neglect).
2. To other individuals when a healthcare professional believes that there is a duty to warn others in order to prevent harm to any individual.
3. To state and federal law enforcement agencies.
4. We may also disclose your name and license plate number (if known) to local law enforcement agencies if we believe you are impaired and unable to operate a motor vehicle and you do so despite your request not to.

SPECIAL PROTECTIONS:

Confidentiality of Minors' Records:

The child's parent or guardian should determine access to the medical records of a minor child (under the age of 19). However, in rare circumstances a child may be emancipated or may state thats/he does not want her/his parents or guardians to have access to the records. A parent may be denied access to their child's medical records if Pelvic Health has been provided with a certified copy of a court order, indicating that the parent has no legal rights and responsibilities for the child.

Requests to us should be made in writing:

We require that any request to inspect or copy records, for amendments to medical records, request for restrictions on contents or usage of your medical record, requests to revoke consent or authorizations, request for accounting of disclosures, and request for confidential communication with you, be made in writing.

Please contact us if you have any questions or concerns about the confidentiality and security of your medical records or about your rights and our responsibilities. 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.

Please call or write:

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