the request or to obtain an order protecting the information the party has requested. 4. Law enforcement. Law enforcement. We may release PHI if asked to do so by a law enforcement official:

You have the following rights regarding the PHI that we maintain about you: 1. Confidential communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to: Ashley P. O’Rourke, PT, DPT, ATC, LAT 138 Long Cove Ln Mooresville, NC 28117 (910) 546-5917 specify the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request. 2. Requesting restrictions. Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree with your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to Ashley P. O’Rourke, PT, DPT, ATC, LAT 138 Long Cove Ln Mooresville, NC 28117 (910) 546-5917 Your request must describe in a clear and concise fashion:

- • Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement,
- • Concerning a death we believe has resulted from criminal conduct,
- • Regarding criminal conduct at our offices,
- • In response to a warrant, summons, court order, subpoena or similar legal process,
- • To identify/locate a suspect, material witness, fugitive or missing person,
- • In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).

5. Deceased patients. Deceased patients. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs. 6. Organ and tissue donation. Organ and tissue donation. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor. 7. Research. Research. Our practice may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when an Internal Review Board or Privacy Board has determined that the waiver of your authorization satisfies all of the following conditions: (A) The use or disclosure involves no more than a minimal risk to your privacy based on the following: (i) an adequate plan to protect the identifiers from improper use and disclosure; (ii) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (iii) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (B) The research could not practicably be conducted without the waiver; (C) The research could not practicably be conducted without access to and use of the PHI. 8. Serious threats to health or safety. Serious threats to health or safety. Our practice may use and disclose your PHI 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. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. 9. Military. Military. Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 10. National Security. National Security. Our practice may disclose you PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal and national securities authorized by law. We also may disclose your PHI to federal officials in order to protect the president, other officials or foreign heads of state, or to conduct investigators. 11. Inmates. Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals. 12. Workers’ compensation. Workers’ compensation. Our practice may release your PHI for workers’ compensation and similar programs.

- • The information you wish restricted,
- • Whether you are requesting to limit our practice’s use, disclosure or both,
- • To whom you want the limits to apply.

3. Inspection and copies. Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Ashley P. O’Rourke, PT, DPT, ATC, LAT 138 Long Cove Ln Mooresville, NC 28117 (910) 546-5917 in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct the reviews. 4. Amendment. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Ashley P. O’Rourke, PT, DPT, ATC, LAT 138 Long Cove Ln Mooresville, NC 28117 (910) 546-5917 You must provide us with a reason that supports your request for amendment. Out practice will deny your request if you fail to submit your request (and reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information. 5. Accounting of disclosures. Accounting of disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain

- E. Your rights regarding your PHI: