Name of Patient (please print) Date of Birth
I hereby acknowledge that I received Back on Track, Inc.
Notice of Privacy Practices.
(found below)
Signature of patient or patient representative Date
To obtain patient's acknowledgment that they received provider's
Notice of Privacy Practices
____/____/____
The patient presented to the office/hospital on (insert date) and was provided with a copy of Back on Track, Inc.'s Notice of Privacy Practices. A good faith effort was made to obtain from the patient a written acknowledgment of his/her receipt of the Notice. However, such acknowledgment was not obtained because:
Patient refused to sign.
Patient was unable to sign or initial because:
The patient had a medical emergency, and an attempt to obtain the acknowledgment will be made at the next available opportunity.
Other reason (describe below):
Signature of patient or patient representative Date
NOTICE OF PATIENT INFORMATION PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION. PLEASE REVIEW IT CAREFULLY.
Back on Track, Inc.’s LEGAL DUTY
Back on Track, Inc. is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein.
USES AND DISCLOSURES OF HEALTH INFORMATION
Back on Track, Inc. uses your personal health information primarily for treatment; obtaining payment for treatment; conducting internal administrative activities and evaluating the quality of care that we provide. For example, Back on Track, Inc. may use your personal health information to contact you to provide appointment reminders, or information about treatment alternatives or other health related benefits that could be of interest to you.
Back on Track, Inc. may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies and for emergencies. We also provide information when required by law.
In any other situation, Back on Track, Inc.’s policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time.
PATIENT’S INDIVIDUAL RIGHTS
You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment or other related administrative purposes.
You may also request in writing that we not use or disclose your personal health information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law or in emergency circumstances. Back on Track, Inc. will consider all such request on a case by case basis, but the practice is not legally required to accept them.
CONCERNS AND COMPLAINTS
If you are concerned that Back on Track, Inc. may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our practice manager at the address listed below. You may also send a written complaint to the US Department of Health and Human Services. For further information on Back on Track, Inc.’s health information practices or if you have a complaint, please contact the following person:
J. Kevin Younger, MPT, CPI
4835 West 10th Street, Suite B, Greeley, Colorado 80634
Telephone: 970-346-6116 Fax: 970-346-1226