NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES

Spencer Goff Physical Therapy Services, Inc.

Effective Date: 5-1-26

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.

1. Our Commitment to Your Privacy

Spencer Goff Physical Therapy Services, Inc. ("we," "us," or "the Practice") is committed to protecting the privacy and security of your health information. We are required by law to:

•      Maintain the privacy of your protected health information ("PHI")

•      Provide you with this Notice of our legal duties and privacy practices regarding your PHI

•      Notify you following a breach of your unsecured PHI

•      Follow the terms of the Notice currently in effect

This Notice applies to all health information we create or maintain about you. It is provided in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the HITECH Act, and the California Confidentiality of Medical Information Act (CMIA).

2. How We May Use and Disclose Your Health Information Without Your Authorization

The following categories describe the ways we may use and disclose your PHI without your written authorization. Not every use or disclosure is listed; however, all permitted uses and disclosures fall within one of these categories.

2.1 For Treatment

We may use and disclose your PHI to provide, coordinate, or manage your physical therapy care. Examples include:

•      Discussing your condition and progress with your referring physician or other treating providers

•      Sharing relevant information with another therapist or provider involved in your care

•      Communicating with your caregivers or family members involved in your treatment, with your permission

2.2 For Payment

We are a fee-for-service, private-pay practice and do not bill insurance. However, we may use or disclose your PHI for limited payment-related purposes, including:

•      Providing you with itemized superbills you can submit to your insurance for possible reimbursement

•      Processing credit card or other electronic payments

•      Pursuing collection of unpaid balances, including referral to a collection agency or attorney if necessary

2.3 For Health Care Operations

We may use and disclose your PHI for activities necessary to operate the Practice, including:

•      Quality assessment and improvement activities

•      Reviewing and evaluating the performance of our staff

•      Conducting training, including supervision of students and clinicians-in-training (with reasonable safeguards to limit identifying information)

•      Business planning, management, and general administrative activities

•      Consulting with attorneys, accountants, or other professional advisors

2.4 Business Associates

We may share your PHI with third parties who perform services on our behalf — for example, our electronic health records vendor, billing software provider, secure messaging platform, document storage provider, or accountant. These "business associates" are required by written agreement to safeguard your PHI in accordance with HIPAA.

2.5 Appointment Reminders and Follow-up

We may contact you to remind you of appointments, follow up on care, or share information about treatment alternatives or health-related services that may interest you. Reminders may be sent by phone, voicemail, text message, or email using the contact information you provide. You may ask us to use a specific contact method or to stop these communications at any time.

2.6 Required by Law

We will use or disclose your PHI when required to do so by federal, state, or local law.

2.7 Public Health and Safety

We may disclose your PHI for public health activities, including:

•      Reporting suspected abuse, neglect, or domestic violence as required or permitted by California law

•      Reporting adverse events related to medical devices or products to the FDA

•      Preventing or controlling disease, injury, or disability

•      Disclosing information to avert a serious and imminent threat to the health or safety of you or others

2.8 Health Oversight, Legal Proceedings, and Law Enforcement

We may disclose your PHI to health oversight agencies for activities authorized by law (such as audits, investigations, or licensure actions); in response to a court or administrative order, subpoena, or discovery request as permitted by HIPAA and California law; and to law enforcement officials in narrowly defined circumstances permitted by law.

2.9 Coroners, Medical Examiners, and Funeral Directors

We may disclose PHI to coroners, medical examiners, or funeral directors as necessary to carry out their duties.

2.10 Workers' Compensation

We may disclose PHI as authorized by, and to the extent necessary to comply with, California workers' compensation laws.

2.11 Specialized Government Functions

In limited circumstances, we may disclose PHI for military and veterans' activities, national security, protective services for the President, or correctional institution purposes.

3. Uses and Disclosures That Require Your Written Authorization

The following uses and disclosures will be made only with your written authorization:

•      Most uses and disclosures of psychotherapy notes (if any are maintained)

•      Uses and disclosures for marketing purposes, except for face-to-face communications and certain promotional gifts of nominal value

•      Disclosures that constitute a sale of PHI

•      Use or disclosure of photographs, video, or audio recordings of you for educational or promotional purposes

•      Any other use or disclosure not described in this Notice

You may revoke your authorization in writing at any time, except to the extent we have already relied on it. Revocation will apply to future uses and disclosures.

4. Additional Protections Under California Law

California's Confidentiality of Medical Information Act (CMIA) and other state laws provide protections in addition to HIPAA. These include, but are not limited to:

•      Stricter limits on the disclosure of medical information for marketing purposes

•      Heightened protections for information related to mental health, substance use treatment, HIV/AIDS status, genetic testing, and reproductive health

•      The right to request that we not disclose information about a service to your health plan if you have paid in full out of pocket

•      Specific requirements regarding minors' access to and control over their own health information in certain circumstances

Where state law is more protective than HIPAA, we will follow the more protective standard.

5. Your Rights Regarding Your Health Information

You have the following rights with respect to PHI we maintain about you. To exercise any of these rights, please submit a written request to the Privacy Officer using the contact information at the end of this Notice.

5.1 Right to Access and Receive Copies

You have the right to inspect and receive a copy of your PHI, including in an electronic format if we maintain it electronically. We may charge a reasonable, cost-based fee permitted by California law. We will respond to your request within the time frames required by law.

5.2 Right to Request Amendment

If you believe information in your record is incorrect or incomplete, you have the right to request that we amend it. We may deny your request under certain circumstances, but you have the right to submit a written statement of disagreement that will be included with your record.

5.3 Right to an Accounting of Disclosures

You have the right to request a list of certain disclosures of your PHI we have made. The list will not include disclosures made for treatment, payment, health care operations, disclosures made with your authorization, or certain other categories excluded by law. You may request an accounting for disclosures made in the six years prior to your request (or a shorter period you specify). The first accounting in any 12-month period is free; we may charge a reasonable cost-based fee for additional requests.

5.4 Right to Request Restrictions

You have the right to request restrictions on how we use or disclose your PHI for treatment, payment, or health care operations, or to family members involved in your care. We are not required to agree to most requested restrictions. However, we are required to agree if you request that we not disclose information to a health plan about a service you have paid for in full out of pocket — which generally applies to all of our services as a private-pay practice.

5.5 Right to Confidential Communications

You have the right to request that we communicate with you by alternative means or at an alternative location (for example, by mail to a P.O. box rather than your home address, or only by phone and not by email). We will accommodate reasonable requests.

5.6 Right to a Paper Copy of This Notice

You have the right to a paper copy of this Notice at any time, even if you have agreed to receive it electronically.

5.7 Right to Be Notified of a Breach

You have the right to be notified in the event of a breach of your unsecured PHI, as required by law.

5.8 Right to File a Complaint

If you believe your privacy rights have been violated, you may file a complaint with us using the contact information below, or with the U.S. Department of Health and Human Services, Office for Civil Rights:

•      Online: www.hhs.gov/ocr/privacy/hipaa/complaints

•      Mail: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201

•      Phone: 1-877-696-6775

You may also file a complaint with the California Attorney General's Office or the California Department of Public Health. We will not retaliate against you for filing a complaint.

6. Changes to This Notice

We reserve the right to change this Notice and to make the revised Notice effective for all PHI we maintain. The current Notice will be posted in our office and on our website (if applicable), and a copy will be provided to you on request. The effective date of the current Notice is shown at the top of this document.

7. Contact Information

If you have questions about this Notice, wish to exercise any of your rights, or want to file a complaint, please contact our Privacy Officer:

Privacy Officer: Spencer Goff, PT, DPT

Spencer Goff Physical Therapy Services, Inc.

Address: 265 Santa Helena #110, Solana Beach, CA 920275

Phone: 619-248-5962

Email: NeuroRehabTTE@gmail.com

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By signing below, I acknowledge that I have received, or have been offered, a copy of the Notice of Privacy Practices of Spencer Goff Physical Therapy Services, Inc.

Patient Printed Name: ______________________________________________

Signature: X__________________________________ Date: ______________

If signed by a personal representative:

Printed Name: ______________________________ Relationship/Authority: ______________________________

Signature: X__________________________________ Date: ______________

For office use only:

☐ Acknowledgment received.

☐ Acknowledgment not obtained. Reason: ______________________________________________

Staff signature: ______________________________ Date: ______________

Form version: 5-1-26