Effective Date: 4/14/2003


If you have any questions about this notice, please contact the office manager

WHO WILL FOLLOW THIS NOTICE: Comprehensive Sports Care Specialists, Inc.


We understand that health information about you and your health care is personal and we are committed to protecting health information about you.

We must create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care that are generated by this health care practice, whether made by your physical therapist or by other personnel. This notice will advise you of the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, as well as certain obligations we have regarding the use and disclosure of your health information.

We are required by law to:

  • Make sure that health information that identifies you is kept private
  • Give you this notice of our legal duties and privacy practice with respect to health information about you
  • Follow the terms of the notice that are currently in effect


The following categories describe ways that we use and disclose health information. Not every use or disclosure in a category will be listed; however, all of the ways we are permitted to use and disclose information will fall within one of the categories.

Treatment: We may use health information about you to provide you with health care treatment or services. We may disclose health information about you to doctors, nurses, technicians, health care students, or other personnel who are involved in taking care of you. They may work at our offices or your doctor's office, or may be other health care providers to whom we may refer you for consultation, to have testing performed, or for other treatment purposes.

Payment: We may use and disclose health information about you so that treatment and services you receive from us may be billed to and payment collected from you, an insurance company or a third party. For example, we may need to give information about your office visit to your health plan so your health plan will pay us or reimburse you for the visit. We may also tell your health plan about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment.

Health Care Operations: We may use and disclose health information about you for operations of our health care practice. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use your health information to review our treatments and services and to evaluate the performance of our staff. We may also combine health information about many patients to help determine what additional services should be offered, what services are not required, whether certain treatments are effective and to determine where we can make improvements. We will remove from this set of health information any information that identifies the patient so others may use it to study health care delivery without learning who our specific patients are.

As Required By Law: When required by Federal, State or Local Law we will disclose health information about you.

To Avert a Serious Threat to Health or Safety: When necessary, we may use and disclose health information about you to prevent a serious threat to your health and safety, the health and safety of the public, or the health and safety of another person. However, any disclosure would be only to someone able to help prevent the threat.

Military and Veterans: If you are a member of the armed forces or are separated/discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans Affairs as may be applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities.

Worker's Compensation: We may release health information about you for worker's compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks: We may disclose health information about you for public health activities. The activities generally include the following:

  • To prevent or control disease, injury or disability
  • To report child abuse or neglect
  • To report reactions to medications or problems with products
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
  • To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will make this disclosure only if you agree, or when we are required or authorized to do so by law

Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections and licensure which are necessary for the government to monitor the health care systems, government programs and compliance with civil rights laws.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requisition.

Law Enforcement: We may release health information if asked to do so by a law enforcement official as follows:

  • In reporting certain injuries, gunshot wounds, burns, and injuries to perpetrators of crime, as required by law
  • In response to a court order, subpoena, warrant, summons or similar process
  • To identify or locate a suspect, fugitive, material witness, or missing person's name, address, date of birth, social security number, type of injury, date and time of treatment (if applicable), and/or a description of distinguishing physical characteristics
  • About the victim of a crime, if the victim agrees to disclosure or, under certain limited circumstances, when we are unable to obtain the person's agreement
  • About a death we believe may be the result of criminal conduct
  • About criminal conduct at our facility
  • In emergency circumstances to report a crime, the location of the crime or victims, and/or the identity, description or location of the person who committed the crime

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and obtain a copy of health information that may be used to make decisions about your care. This usually includes health and billing records.

In order to inspect and/or receive a copy of health information that may be used to make decisions about you, you must submit your request in writing to our office. If you request a copy of the information, we may charge a fee for the cost of services associated with your request. We may deny your request to inspect and/or receive a copy of your medical records in very limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. Another licensed health care professional chosen by our practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information. To request an amendment, your request must be made in writing. Your request must include a reason that supports your request for an amendment. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request to amend information for any or all of the following reasons:

  • If the information was not created by our office
  • If the information is not part of the health information kept by or for our practice
  • If the information is not part of the information which you would normally receive a copy of or be permitted to inspect
  • If the information is accurate and complete

Any amendment we make to your health information will also be disclosed to those with whom we disclose information as previously specified.

Right to an Accounting of Disclosures: You have the right to request a list accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment, payment and healthcare operations as previously described.

To request this list of disclosures you must submit your request in writing. Your request must state a time period for health records which may not be longer than six years. There will be no charge for the release of the first list; however, we may charge you for the costs of providing additional lists. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We will mail you a list of disclosures in paper form within 30 days of your request. If we are unable to supply the list within 30 days, we will notify you and advise you of the date the list will be available, not to exceed 60 days from the date we received your request.

Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the health information we can disclose to someone who is involved in your care or the payment of your care, such as a family member or friend. For example, you may ask that we restrict a specific therapist from the use of your information, or that we do not disclose information to your spouse about a treatment you had. To request a restriction, you must make your request in writing. In your request, you must tell us what the information should be limited to and to whom you want the limits to apply; for example, the use of any information by a specified therapist, or disclosure of a specified treatment to your spouse.

We are not required to agree to your request for restriction if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you. If we agree with your request, we will comply, unless the information is needed to provide emergency treatment for you.

Right to Request Confidential Communications: You have the right to request that we communicate with you about health matters in a certain location. For example, you can ask that we only contact you at work or by mail to a post office box.

To request confidential communications, you must make your request in writing. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice at any time. CHANGES TO THIS NOTICE

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint, it must be submitted in writing. YOU WILL NOT BE PENALIZED FOR FILING A COMPLAINT.


Other uses and disclosures of your health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to reverse any disclosures we have already made with your permission, and that we are required to retain our records for the care that we provided to you.

Acknowledgement of Receipt of This Notice

We will request that you sign a separate form or notice acknowledging that you have read or received a copy of this notice. If you are unable to sign, or choose not to do so, a staff member will sign their name and date. This acknowledgement will be filed with your records.