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Patient Privacy

[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column][vc_column_text el_class=”yellowBox”]Privacy Policy[/vc_column_text][vc_column_text el_class=”whiteBox”]Synergy Physical Therapy, Inc. will comply with all Federal, State and professional standards and regulations relating to the use and disclosure of protected health information, regardless of the medium in which it exists. We have a Notice of Privacy Practices that details our procedures in complying with legal and ethical mandates that guide us.


Covered Entity: Per HIPAA a covered entity is:

  1. Health Plan
  2. Provider
  3. Clearinghouse


We are required by federal and state law and ethical standards to protect the privacy of our patient’s health information. For example, federal health information privacy regulations require us to protect information about the patient in the manner that we describe in our Privacy Notice. Certain types of health information may specifically identity the patient. Because we must protect this health information we call this Protected Health Information—or “PHI”. In our Privacy Notice, we describe:

  1. How we use PHI
  2. When we may disclose PHI to others
  3. The Patient’s Privacy Rights and how to use them
  4. Our privacy duties
  5. Who to contact for more information and/or complaints

Synergy Physical Therapy, Inc. Uses, Discloses and Releases Protected Health Information in the following manner and under the following conditions, they are:

Use and Disclosures for Treatment, Payment & Healthcare Operation


We use and disclose PHI in the course of a patient’s treatment. For instance, once we have completed an evaluation or re-evaluation we send a copy or summary of our report to the patient’s referring practitioner, if applicable. We also maintain records detailing the care and services that the patients receive at our facility so that we can be accurate and consistent in carrying out that care in an optimal manner. That record also assists us in meeting certain other professional and legal requirements. These records maybe used and/or disclosed by members of our workforce to assure that proper care is rendered. Synergy Physical Therapy, Inc. will adhere to the ‘minimal necessary’ stipulations as noted in HIPAA Policy 6.007.


After we treat a patient we will, typically, bill a third party for the services delivered. We will collect the treatment information and enter the data into our computer and then process a claim either on paper or electronically. The claim will note the patient’s health problem, what treatments were rendered and it will include other information such as the patient’s social security number, insurance policy number and other identifying pieces of information. The third party payer may request a copy of the patient’s treatment records to assist them in determining that the services were medically necessary.

Health Care Operations

We also use and disclose PHI in our health care operations. For example our therapists meet periodically to review clinical records to monitor the quality of care at our facility. Patient records and PHI could be part of these quality assessments. Sometimes we provide student internship programs and we use the PHI of actual patients to test their skills and knowledge. Other health care data (PHI) may be involved in business planning, compliance monitoring or even in the investigation and/or the resolution of a complaint.

Special Uses

We also may use or disclose PHI to assist us in carrying out certain responsibilities to our patients, such as to:

i) Remind patients of appointments

ii) Release equipment and/or supplies to a patient’s designee

iii) Carry out follow ups on home programs or discharge planning

iv) Advise patients of new or updated services or home supplies via telecommunication or via a newsletter

v) Carry out research that does not directly identify the patient

vi) Carry out marketing functions such as providing nominal promotional gifts

vii) Notify the patient of fundraising functions

Note: A patient may opt-out of notification and/or engagement in all of the above

Uses and Disclosures for Treatment, Payment & Health Care Operations

Many laws and regulations apply to us that affect a patient’s PHI; they may either require or permit us to disclose it. The following is a list from the federal health information privacy regulations describing required or permitted uses and disclosures:


i) We may share PHI with a family member or friend if he/she is clearly involved with the patient’s care and if the patient does or has not object (verbally)

ii) We may use PHI in an emergency if the patient is unable to express him or herself

iii) We may use or disclose a patient’s PHI for research, if we receive specific assurances that protect the privacy of the individual

iv) We may update the patient’s workers compensation case worker or employer


i) We must release PHI when required by law i.e. ordered by a court

ii) We must report communicable diseases or adverse reactions to drugs to the appropriate public health or federal department or agency

iii) We must report neglect, abuse or domestic violence

iv) We must allow access to and disclosure of PHI to government regulators for compliance audits and surveys

v) We must allow access to or provide PHI as a response to a judicial or administrative proceeding such as a valid subpoena or protective order

vi) We must report and/or respond to legal requests of law enforcement officials or other legal entities relating to criminal activities such as gunshot wounds

vii) We must disclose PHI to advert a health hazard or to respond to a public health threat such as an imminent crime against another person

viii) We must release the PHI of a member of the armed forces upon request of the appropriate military command authorities

ix) We must release PHI in connection with certain types of organ donor programs

Authorization for the Release of Protected Health Information

Only under the conditions noted above (Sections 1 & 2) do we have the right to use and disclose a patient’s protected health information without a patient’s authorization. If a patient desires to provide access to his/her PHI, for instance access to his/her PHI to designees or participate in a research project we will provide an authorization form for his/her completion. In certain circumstances this facility may need or desire to use and/or disclose a patient’s PHI, in this situation we must secure his/her permission and provide the patient with an authorization form for completion to obtain his/her consent. An example is; an authorization would be required by law to allow Synergy Physical Therapy, Inc. to directly or indirectly receive compensation in exchange for accessing a patient’s PHI.

Synergy Physical Therapy, Inc. has a HIPAA compliant Authorization for Release of PHI Form, HIPAA-143, and considers this the most appropriate tool for a valid authorization. The patient may revoke his/her authorization at any time with a written notice (see HIPAA Policy 6.003) using the Authorization Revocation Form HIPAA-152.

Procedure for Authorization and Release of Information

When a patient, or legal representative of the patient, registers on his/her first visit he/she will be given an Authorization for Release of PHI Form HIPAA-143 form to review and complete if they agree and desire to do it at that point, otherwise it will be provided upon request

  1. The Business Office staff will be the first-line source for answering question about the Authorization Form, however the HIPAA Officer will be the primary contact for non-routine questions.
  2. Once the patient fills out the Authorization Form he/she will give it to the Business Office staff member who will then review it for completion. If the form is complete the Business Office staff member will make one copy of the form, one for the patient’s chart and one for the patient. The original will be filed in the patient’s chart.
  3. If an incidental request for access (e.g.) request to speak to or give a message to a patient) is received by the Business Office the person accepting the request will check for the Authorization Form for the requestor’s authorized access and then will proceed to validate the identity of the requestor. The Business Office staff member will then release or decline to release the information based on the authorization permits and identity validation. Authorized disclosures of PHI are not subject to disclosure accounting.
  4. If a request is mailed or faxed to the Business Office the staff designee will check to see if an Authorization Form for the requestor’s authorized access is available and will validate the person’s identity and will release or decline to release the information based on his/her findings. If the release is permitted and/or required per “HIPAA’s Required Listed noted in 2b (i-ix) and is substantiated as ‘required’ the subject, date and purpose of the release will be logged on the Accounting for Disclosures Form HIPAA-155 and the release of the PHI will occur.
  5. All validated requests for release of PHI are subject to reproduction and labor cost fee with the exception those from healthcare providers, workers’ compensation case workers/employers, etc., schools and not-for-profit organizations.
  6. All requests for release of PHI, in any medium, will be honored within thirty (30) days of receipt of a valid authorization from the patient and written request from the requesting party
  7. If a requester is denied access to any PHI, including but not limited to, the presence of the patient in the clinic, the requestor will be told that Synergy Physical Therapy, Inc. is restricted from releasing any information without proper authorization. He/she will be advised to contact the patient directly to obtain that authorization.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us using the information below. If you believe that we may have violated your privacy rights, or you disagree with a decision we made about access to your protected health information or in response to a request you made, you may complain to us using the contact information below. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to protect the privacy of your protected health information. We will not retaliate in anyway if you choose to file a complaint with us or with the U.S. Department of Health and Human Services

Name of Contact Person:

Synergy Physical Therapy Inc.
Telephone: (707) 462-8080
Address: 206 Mason Street, Suite B
Ukiah, CA 95482[/vc_column_text][/vc_column][/vc_row]