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Notice of Privacy Practices

Your Information. Your Rights. Our Responsibilities.

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.

Your Rights

• Get a copy of your paper or electronic medical record

• Correct your paper or electronic medical record

• Request confidential communication

• Ask us to limit the information we share

• Get a list of those with whom we’ve shared your information

• Get a copy of this privacy notice

• Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition

• Provide disaster relief

• Include you in a hospital directory

• Provide mental health care

• Market our services and sell your information

• Raise funds

Our Uses and Disclosures

We may use and share your information as we:

• Treat you

• Run our organization

• Bill for your services

• Help with public health and safety issues

• Do research

• Comply with the law

• Respond to organ and tissue donation requests

• Work with a medical examiner or funeral director

• Address workers’ compensation, law enforcement, and other government requests

• Respond to lawsuits and legal actions

Your Health Information

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on our website or through the privacy official below.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.

If we have your substance use disorder patient records, subject to 42 CFR part 2, we will give you clear and obvious notice in advance and a choice about whether to receive fundraising communications that use your Part 2 information.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

• Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

• Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

• Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

In all cases, including those listed below, if we have substance use disorder patient records about you, subject to 42 CFR part 2, we cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your consent or (2) a court order and a subpoena.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease / Helping with product recalls / Reporting adverse reactions to medications / Reporting suspected abuse, neglect, or domestic violence / Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

Effective date: 10/1/2022

Privacy Official:

Jacquelyn Bullock

Email:

jackie@glacierpeakspt.com

Phone #: 406-426-1560

Release of Information

I acknowledge receipt of the Notice of Privacy Practices from Glacier Peaks Mobile Physical Therapy LLC. I understand that the Notice of Privacy Practices provides information about how Glacier Peaks Mobile Physical Therapy LLC may use and disclose my protected health information. I have reviewed it and understand that the Notice of Privacy Practices is subject to change. If the Notice is changed, I may request a revised copy.

I hereby authorize that the payment of authorized benefits be made directly to Glacier Peaks Mobile Physical Therapy LLC of any services that are reimbursable by Medicare or my specific insurance plan if applicable.

I hereby consent to such treatment procedures and patient care which, in the judgment of my therapist and/or physician, may be considered necessary or advisable while I am a patient of Glacier Peaks Mobile Physical Therapy LLC

I hereby guarantee payment for any and all services rendered to me which are not covered or allowable by Medicare or my specific insurance plan, together with collection costs, including reasonable attorney fees. I also understand that all bills are due and payable upon presentation. I understand that the client responsibility portion of my bill shall be due and payable at time of services. I understand that I am personally responsible for full payment of all charges including Medicare or my specific insurance plan denials, deductibles and copayment fees. I understand that Glacier Peaks Mobile Physical Therapy, LLC does not submit to any other insurances, unless negotiated prior to start of service. I understand that I will be provided with an invoice for services not covered by Medicare or my specific insurance plan in which I can submit my own insurance for reimbursement in consideration of services rendered to me by Glacier Peaks Mobile Physical Therapy LLC.

I hereby certify that the information given by me in applying for payment under title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any such information needed for this or a related Medicare Claim. I request that the payment of authorized benefits be made on my behalf. I understand that I am responsible for any health insurance deductibles and co-insurance. I understand that I cannot receive Medicare Part B services in the home if I am currently on Home Health under Medicare Part A and or on Hospice Care. I understand that services must be skilled and medically necessary to be covered by Medicare Part B. I understand Medicare will pay for 80% of the allowed amount, and I am responsible for the remaining 20% if I do not have a secondary insurance. I understand that Glacier Peaks Mobile Physical Therapy LLC will notify me prior to charging my credit card for any outstanding balance(s) by email and/or mail.

We offer a discounted private payment rate when patients pay the day of service in exchange for the prompt payment and the reduction in administrative work/time since we do not have to file claims or obtain pre-authorization. This prompt payment discount is offered to clients who do not have insurance or who choose not to use their health plan benefits. If we are in-network with your health plan, our prompt payment rate may be less than the in-network rate that we have negotiated with your health plan. If you choose to take advantage of our discounted private payment policy, you understand that we will not submit a claim to your health plan and you agree that you will not submit our claims or statements to your health plan in an attempt to get reimbursed for our services. If you choose to pay privately initially and later want to switch to using your health plan, you understand that the fees for our services may be higher and you will no longer be entitled to our discounted private pay price. Your ability to switch to using your health plan benefits may also be limited by your health plan’s requirements for pre-authorization or other policy limitations.

I understand that the services being provided will not be billed to insurance. That I will not submit the claims to my insurance, and that payment is due to Glacier Peaks Mobile Physical Therapy LLC day of service for any private pay services.

Glacier Peaks Mobile Physical Therapy LLC may securely store my credit/debit card and charge it for:

I understand that: My card will only be charged after services are rendered or when a balance becomes due. I will receive a receipt for all charges. I may update or remove my card information at any time by contacting the clinic.

I hereby understand that if I fail to cancel my appointment within the 24 hour period prior to my appointment, I will be responsible for a cancellation fee of $50. I will notify Glacier Peaks Mobile Physical Therapy LLC via phone call, text or email 24 hours prior to my scheduled appointment if I need to cancel or reschedule my appointment. I understand that Glacier Peaks Mobile Physical Therapy LLC will notify me prior to charging my credit card for any outstanding balance(s) by email and/or mail.

I hereby understand that I will be notified of my Out of Pocket Expense, my Co-payment, and my Deductible according to my current insurance policy, prior to receiving any treatments. I will have the opportunity to forgo treatment if I do not wish to make those obligatory payments to Glacier Peaks Mobile Physical Therapy LLC

Email and Text Messaging Agreement

We appreciate having the ability to communicate with you by email or text messaging as this is often the most convenient method for both therapists and clients. However, it is possible that email and text messaging security can be compromised, and it is beyond the control of Glacier Peaks Mobile Physical Therapy LLC to maintain the security of communications beyond using routine internet safety practices and safeguards. You may opt out of text messaging or email communications at any time by communicating with us about your preferences. By opting out of texts or emails you will be opting out of our appointment reminder system as well.

Notice of Use of AI Scribe and Consent

To improve your care, our practice may use an AI powered medical scribe during visit. This tool allows us to focus more on you, the patient, and less on computer documentation.

What is an AI Scribe?

The AI scribe is a tool that listens to the conversation during a therapy session and generates a draft therapy note. Your therapist reviews and approves the note before it is saved to your medical record.

How will this affect you?

The AI tool does not interact with you directly. It merely listens to the conversation and creates a summary. This can allow the therapist to focus more on the visit and less on taking notes.

Data Privacy and Confidentiality

The AI tool adheres strictly to Health Insurance Portability and Accountability Act (HIPAA) compliance guidelines to ensure your data is secured and protected. Only the healthcare professionals involved in your care will have access to these notes.

By continuing with your session, you acknowledge and consent to the use of this technology as part of your care documentation process.