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 medical information is the information
gathered by your therapists or other caregivers during the time you are being
treated by Sciform Physical Therapy, Inc. (“Sciform Physical Therapy”)
professionals. Your medical information includes all information within your
record, including but not limited to, symptoms, examination, and test results,
diagnoses, treatment, plans for future care and treatment, at home regimens,
and billing related information, including contact information. It is private,
and no one without a legitimate need to know may have access to it. Sciform
Physical Therapy is required by law to maintain the privacy of your health
information and to provide you with a notice of its legal duties and privacy
practices. Sciform Physical Therapy will promptly notify affected individuals
following a breach of unsecured protected health information.

Sciform Physical Therapy will not use or
disclose your health information except as described in this Notice of Privacy
Practices (“Notice”). This Notice applies to all of the medical records
generated during your participation in Sciform Physical Therapy programs and
services.

USES AND DISCLOSURES
OF PROTECTED HEALTH INFORMATION

The following categories describe the ways
that Sciform Physical Therapy may use and disclose your health information
without a specific
authorization from you:

• Treatment: Sciform Physical Therapy will use your health
  information in the provision and coordination of your healthcare. We may
  disclose all or any portion of your medical record information to your
  physician, consulting physician(s), nurses and other healthcare providers
  who have a legitimate need for such information in the care and continued
  treatment of the patient.
• Payment: Sciform Physical Therapy may use and disclose
  medical information about you for the purposes of billing and collecting
  payment from you, your insurance company or another third party payor;
  reimbursement; determining coverage, claims management,; and medical data
  processing. The information may be released to an insurance company,
  third-party payor or other entity (or their authorized representatives)
  involved in the payment of your medical bill and may include copies or
  excerpts of your medical record that are necessary for payment of your
  account. For example, a bill sent to a third party payor may include
  information that identifies you, your diagnosis, the procedures and
  supplies used.
• Routine Healthcare Operations: Sciform Physical Therapy may use and disclose
  your medical information during routine healthcare operations, including
  quality assurance, utilization review, internal auditing, accreditation,
  certification, licensing or credentialing activities of each
  rehabilitation clinic (“Clinic”), medical research and educational purposes.
• Business Associates: Sciform Physical Therapy may use and disclose
  certain medical and billing information about you to business associates.
  A business associate Sciform Physical Therapy contracts with to perform
  services on its behalf. A business associate is an individual or entity
  under contract with Sciform Physical Therapy to perform or assist Sciform
  Physical Therapy in a function or activity that necessitates the use or
  disclosure of medical information. Examples of business associates include
  but are not limited to, a copy service used by the Clinic to copy medical
  records, consultants, independent contractors, accountants, lawyers,
  medical transcriptionists and thirdparty billing companies. Sciform
  Physical Therapy requires the business associate to protect the
  confidentiality of your medical information.
  In addition, Sciform Physical Therapy requires anySciform
  Physical Therapy’s business associate to protect the confidentiality of
  your medical information.
  Sciform Physical Therapy and its business associates may use and disclose
  your medical information to remind you about your appointments, assess
  your satisfaction with our services, to collect payments, or to monitor
  compliance with your home exercise program, among other things.
• Required by Law: Sciform Physical Therapy will disclose medical
  information about you when required to do so by law.
• Public Health Activities: Sciform Physical Therapy may disclose your
  medical information to public health or legal authorities charged with
  preventing or controlling disease, injury or disability.
• Victims of Abuse, Neglect or
  Domestic Violence: Sciform
  Physical Therapy may disclose your health information to a public health
  authority that is authorized to receive reports of abuse, neglect, or
  domestic violence. We may make an effort to obtain your permission before
  releasing this information, but in some cases may be required or
  authorized to act without your permission.
• Health Oversight, Licensing,
  Accreditation and Regulatory Activities: Sciform
  Physical Therapy may disclose your health information to health oversight
  agencies authorized to conduct audits, investigations, and inspections of
  our facility. For example, billing practices may be audited by the State
  Auditor and records are subject to review by the Secretary of Health and
  Human
  Services and his/her authorized representatives.
• Judicial or Administrative
  Proceedings: Sciform Physical Therapy
  may disclose your health information if we are ordered to do so by a court
  or an administrative hearing officer that is handling a lawsuit or other
  dispute or provided with a valid subpoena.
• Disclosures for Law Enforcement
  Purposes: Sciform Physical Therapy
  may disclose your identity to law enforcement. Instances which may result
  in a disclosure of protected health information to law enforcement include
  to comply with court orders or assist with ongoing investigations
• Coroners, Medical Examiners and
  Funeral Directors: Sciform
  Physical Therapy may disclose protected health information to a coroner,
  medical examiner or funeral director for the purposes of identifying a
  deceased person or other duties as authorized by the law.
• Research: In some instances, Sciform Physical Therapy can
  use or share your health information for health research.
• To Avert a Serious and Imminent
  Threat to Health or Safety: Sciform
  Physical Therapy may use or disclose your protected health information
  when necessary to prevent a serious and imminent threat to your health or
  safety, or the health or safety or another person or the public.
• Specialized Government
  Functions: If you are an inmate of a
  correctional institution or under the custody of a law enforcement
  officer, Sciform Physical Therapy may release your medical record
  information to the correctional institution or law enforcement official. Sciform
  Physical Therapy may also disclose your medical information as required by
  military command authorities if you are a
  member of the armed forced.
• Workers’ Compensation: Sciform Physical Therapy may release medical
  information about you for workers’ compensation or similar programs that
  provide benefits for work-related injuries or illnesses.

PATIENT CHOICES

You have the right and choice to tell us which
information to share with your family, close friends, or others involved in
your care, and if you would like us to share your information in a disaster
relief situation. 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.

Except for the situations and exceptions
described in this Notice, we will need to obtain your written authorization
before using or disclosing your protected health information for other
purposes. For example, except as otherwise set forth under State and Federal
law, we must obtain your written authorization for most uses or disclosures of
any psychotherapy notes related to you, for the use or disclosure of your
protected health information for marketing purposes, or for the sale of your
protected health information.

PATIENT INFORMATION
RIGHTS

Although all records concerning your treatment
obtained at Sciform Physical Therapy are the property of Sciform Physical
Therapy, you have the following rights concerning your medical information:

• Right to Confidential
  Communications: You have the right to
  receive confidential communications of your medical information by
  alternative means or at alternative locations. For example, you may
  request that Sciform Physical Therapy contact you only at work or by mail.
• Right to Inspect and Copy: You have the right to inspect and copy your
  medical information.
• Right to Amend: You have the right to amend your medical
  information. Any request for amendment should be submitted to Sciform
  Physical Therapy in writing, stating a reason in support of the amendment.
• Right to an Accounting: You have the right to obtain an accounting of the
  disclosures of your medical information made during the preceding six (6)
  year period.
• Right to Request Restrictions: You have the right to request restrictions on
  certain uses and disclosures of your medical information. Sciform Physical
  Therapy is not required to honor your request except where: (i) the
  disclosure is for the purpose of carrying out payment or healthcare
  operations and is not otherwise required by law, and (ii) the medical
  information pertains solely to a healthcare item or service for which you,
  or person other than the health plan on your behalf, has paid Sciform
  Physical Therapy in full.
• Right to Receive a Paper Copy: You have the right to receive a paper copy of
  this Notice, even if you have previously agreed to receive the Notice
  electronically.
• Right to Receive Electronic
  Copies: You have the right to
  receive electronic copies of your medical information.
• Right to Transfer Records: You may also initiate the transfer of your
  records to another person by completing a written authorization form.
• Right to Revoke Authorization: You have the right to revoke your authorization
  to use or disclose your medical information, except to the extent that
  action has already been taken in reliance on your authorization. A request
  to exercise any of these rights must be submitted, in writing, to Sciform
  Physical Therapy, Inc.

FOR MORE INFORMATION
OR TO REPORT A PROBLEM

If you have questions and would like
additional information, you may contact our HIPAA Privacy Officer, at (689) 766-7957
or sciformfrontdesk@gmail.com If you believe your privacy rights have been
violated, you may file a complaint with Sciform Physical Therapy or with the
Secretary of the Department of Health and Human Services.

To file a complaint with Sciform Physical
Therapy, please contact the Front Desk located near the front entrance to the
Clinic. All complaints must be submitted in writing. There will be no
retaliation for filing a complaint.

CHANGES TO THIS NOTICE

Sciform Physical Therapy will abide by the
terms of the Notice currently in effect. Sciform Physical Therapy reserves the
right to change the terms of its Notice and to make the new Notice provisions
effective for all protected health information that it maintains. An updated
version of the Notice may be obtained at the Clinic and on our web site at www.sciformpt.com.

NOTICE EFFECTIVE DATE

This Notice is effective as of July 2022.