Work-Related Injury Intake

NOTICE OF PRIVACY PRACTICES Advanced Health & Physical Therapy Solutions Effective October 1, 2026 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. ──────────────────────────────────────────────────────────────────── OUR COMMITMENT TO YOUR PRIVACY Advanced Health & Physical Therapy Solutions is committed to protecting the privacy and security of your protected health information ("PHI"). This Notice describes how we may use and disclose your PHI to provide your care, obtain payment, run our practice, and for other purposes permitted or required by law. It also describes your rights regarding your PHI. We are required by law to: • Maintain the privacy and security of your PHI; • Provide you with this Notice of our legal duties and privacy practices regarding your PHI; • Notify you in writing if a breach occurs that may have compromised the privacy or security of your PHI; • Follow the terms of the Notice currently in effect. ──────────────────────────────────────────────────────────────────── HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION Treatment. We use and disclose your PHI to provide, coordinate, and manage your chiropractic care. This includes documenting examinations, ordering or reviewing diagnostic imaging, sharing findings with other providers involved in your care (such as your primary care doctor, physical therapist, or referring practitioner), and consulting with specialists when appropriate. Payment. We use and disclose your PHI to obtain payment for the services we provide. This may include verifying your insurance benefits, preparing and submitting claims (or providing you with a superbill to submit yourself), and following up on outstanding balances. Health Care Operations. We use and disclose your PHI for the day-to-day operation of our practice, such as quality assessment, staff training and review, licensing, and general business management. Appointment Reminders and Health-Related Communications. We may contact you (by phone, text message, email, or mail) with appointment reminders, follow-up instructions, or information about treatment options or services we offer that may be of interest to you. You may opt out of these communications at any time. As Required By Law. We will use and disclose your PHI when required to do so by federal, state, or local law. To Avert a Serious Threat to Health or Safety. We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Other Permitted Uses and Disclosures. We may also use or disclose your PHI for public health activities, health oversight, judicial and administrative proceedings, law enforcement, military and veteran activities, workers' compensation, and certain other purposes when permitted or required by law. ──────────────────────────────────────────────────────────────────── 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 (not typically applicable to chiropractic care); • Uses and disclosures of PHI for marketing purposes (other than face-to-face communications and promotional gifts of nominal value); • Sales of PHI; • Other uses and disclosures not described in this Notice. You may revoke any authorization at any time, in writing, except to the extent that we have already taken action in reliance on it. ──────────────────────────────────────────────────────────────────── YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION Right to Inspect and Copy (§164.524). You have the right to inspect and obtain a copy of the PHI we maintain about you. We will provide your records in the form and format you request, if readily producible. We may charge a reasonable, cost-based fee. Right to Request an Amendment (§164.526). If you believe that PHI we have about you is incorrect or incomplete, you may ask us to amend it. We may deny your request in limited circumstances; if we do, you may submit a written statement of disagreement that becomes part of your record. Right to an Accounting of Disclosures (§164.528). You have the right to receive a list of certain disclosures we have made of your PHI, other than disclosures for treatment, payment, health care operations, or pursuant to your authorization. The first accounting in any 12-month period is free. Right to Request Restrictions (§164.522). You have the right to request a restriction on how we use or disclose your PHI for treatment, payment, or health care operations. We are not required to agree to your request, except in the case of disclosures to a health plan when you have paid in full for the relevant services out of pocket. Right to Request Confidential Communications. You have the right to ask us to communicate with you about your PHI in a particular way or at a particular location (for example, by calling only your cell phone, or sending mail to a specific address). We will accommodate reasonable requests. Right to a Paper Copy of This Notice. You have the right to receive a paper copy of this Notice on request, even if you have agreed to receive it electronically. Right to Be Notified of a Breach. You have the right to be notified following a breach of unsecured PHI in accordance with applicable federal and state law. ──────────────────────────────────────────────────────────────────── HOW TO EXERCISE YOUR RIGHTS OR FILE A COMPLAINT To exercise any of the rights described above, or to ask a question about this Notice or our privacy practices, contact our Privacy Officer: Donald Lavigne, DC Advanced Health & Physical Therapy Solutions 40 Morristown Road Suite 1B, Bernardsville, NJ 07924 Phone: (908) 766-5663 Email: info@ahpts.com If you believe your privacy rights have been violated, you may file a complaint with us using the contact information above, or with the U.S. Department of Health and Human Services, Office for Civil Rights, at: https://www.hhs.gov/hipaa/filing-a-complaint/ We will not retaliate against you for filing a complaint. ──────────────────────────────────────────────────────────────────── CHANGES TO THIS NOTICE We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for PHI we already have about you as well as any information we receive in the future. The revised Notice will be posted at our practice and on our website. ──────────────────────────────────────────────────────────────────── ACKNOWLEDGEMENT You may be asked to sign an acknowledgement that you received this Notice. Your signature does not constitute consent for any specific use or disclosure; it only acknowledges that you received the Notice. If you decline to sign, we will document our good-faith effort to obtain your acknowledgement. ────────────────────────────────────────────────────────────────────