To EVOLVED PHYSICAL THERAPY, LLC patients:

This notice describes how health information about you (as a client of EVOLVED PHYSICAL THERAPY, LLC (EVOLVED PT)) may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created because of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

EVOLVED PT’s commitment to your privacy

EVOLVED PT is dedicated to maintaining the privacy of your health information. EVOLVED PT is required by law to maintain the confidentiality of your health information. EVOLVED PT realizes that these laws are complicated, but EVOLVED PT must provide you with the following important information: How EVOLVED PT may use and disclose your health information; Your privacy rights; EVOLVED PT’s obligations concerning the use and disclosure of your health information.

EVOLVED PT may use and disclose your health information in the following ways.

The following categories describe the different ways in which EVOLVED PT may use and disclose your health information. 1. Treatment. EVOLVED PT may use or disclose your health information to treat you or assist others in your treatment. Additionally, EVOLVED PT may disclose your health information to others who may assist in your care, such as your spouse, children, or parents. Also, EVOLVED PT may share all therapy documentation to your prescribing provider. 2. Payment. EVOLVED PT may use your health information to bill and collect payment for services you receive from EVOLVED PT. EVOLVED PT may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. EVOLVED PT also may use and disclose this information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, EVOLVED PT may use your health information to bill you directly for services and items. 3. Health care operations. EVOLVED PT may need to use and disclose your health information to be able to run its practice at the highest clinical standards and effectively as possible. This could be used to evaluate the performance of EVOLVED PT staff, to determine if our treatment plans are effective, or determine if there are other services EVOLVED PT should be offering. EVOLVED PT may also compare its clinical data with other practices; review it with medical or allied-health students, medical faculty, technicians, and others for teaching and learning purposes. EVOLVED PT will strive to remove information that identifies you from this medical information. 4. Disclosures required by Law. EVOLVED PT will use and disclose your health information when it is required to do so by federal, state, or local law. 5. Appointment Reminders. Client appointments are confirmed before each scheduled appointment by phone, text, or email. Please advise if you do not want appointment reminders from EVOLVED PT.

Use and disclosure of your health information in certain special circumstances

The following circumstances may require EVOLVED PT to use or disclose your health information: 1. To public health authorities and health oversight agencies that are authorized by law to collect information. 2. Lawsuits and similar proceedings in response to a court administrative order. 3. If asked to do so by law enforcement official. 4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. EVOLVED PT will only make disclosure to person or organization able to help prevent the threat. 5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 6. To federal officials for intelligence and national security activities authorized by law. 7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. 8. For Workers’ Compensation and similar programs. Your rights regarding your health information 1. Communications. You can request that EVOLVED PT communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that EVOLVED PT to contact you at home, rather than work. EVOLVED PT may accommodate reasonable requests and is not required to agree to your request. 2. You can request a restriction in EVOLVED PT’s use or disclosures of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain friends. EVOLVED PT is not required to agree to your request; however, if EVOLVED PT does agree, EVOLVED PT is bound by said agreement except when otherwise required by law, in emergencies, or when the information if necessary to treat you. 3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including client medical record, treatment records, and billing records. You must submit your request in writing to EVOLVED PT. 4. You may ask EVOLVED PT to amend your health information if you believe it is incorrect or incomplete, and if the information is kept by or for EVOLVED PT. To request an amendment, your request must be made in writing and submitted to EVOLVED PT. 5. Right to obtain a copy. You are entitled to receive a copy of this notice of privacy practices. You may ask EVOLVED PT to give you a copy of this notice at any time. To obtain a copy of this notice, contact EVOLVED PT. 6. Right to file a complaint. If you believe that your privacy rights have been violated, you may file a complaint with EVOLVED PT, or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing, and you will not be penalized for filing a complaint. 7. Right to provide an authorization for other uses and disclosures. EVOLVED PT will obtain written permission from you to disclose information in ways that have not been identified in this notice or are not permitted by these laws.