### Effective Date: 8/1/2019

# Tidal Sports Rehab & Recovery, LLC

Notice of Privacy Practices As required by the privacy regulation created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.

## PLEASE REVIEW THIS NOTICE CAREFULLY.

- A. Our commitment to your privacy:

management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations. 4. Appointment reminders. Appointment reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment. 5. Treatment options. Treatment options. Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives. 6. Health-related benefits and services. Health-related benefits and services. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you. 7. Release of information to family/friends. Release of information to family/friends. Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a baby sitter take their child to the pediatrician’s office for treatment of a cold. In this example, the baby sitter may have access to the child’s medical information. 8. Disclosures required by law. Disclosures required by law. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law. D. Use and disclosure of your PHI in certain special circumstances: Use and disclosure of your PHI in certain special circumstances: The following categories describe unique scenarios in which we may use or disclose your identifiable health information: 1. Public health risks. Public health risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at this time. We realize that these laws are complicated, but we must provide you with the following important information:

- • How we may use and disclose your PHI,
- • Your privacy rights in your PHI,
- • Our obligations concerning the use and disclosure of your PHI.

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our office in a visible location at all times, and you may request a copy of our most current Notice at any time.

- B. If you have any questions about this Notice, please contact:
- • Maintaining vital records, such as births and deaths,

Ashley P. O’Rourke, PT, DPT, ATC, LAT 138 Long Cove Ln Mooresville, NC 28117 (910) 546-5917

- • Reporting child abuse or neglect,
- • Preventing or controlling disease, injury or disability,
- • Notifying a person regarding potential exposure to a communicable disease,
- C. We may use and disclose your PHI in the following ways:

The following categories describe the different ways in which we may use and disclose your PHI. 1. Treatment. Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests or imaging), and we may use the results to help us reach a diagnosis. We might use your PHI in order to recommend a prescription for you. Many of the people who work for our practice – including, but not limited to, our therapists and aides – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment. 2. Payment. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts. 3. Health Care Operations. Health Care Operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-

- • Notifying a person regarding a potential risk for spreading or contracting a disease or condition,
- • Reporting reactions to drugs or problems with products or devices,
- • Notifying individuals if a product or device they may be using has been recalled,
- • Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information,
- • Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

2. Health oversight activities. Health oversight activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and health care system in general. 3. Lawsuits and similar proceedings. Lawsuits and similar proceedings. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of