Privacy Policy


(Revised 2012)



This is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). 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.


At Coppola Physical Therapy, we are committed to treating and using protected health information about you responsibly. This Notice of Health Information Privacy Practices describes the personal health information we collect, and how and when we use or disclose that information. This notice also describes your rights as they relate to your protected health information. This Notice is effective April 14, 2003, and applies to all protected health information as defined by federal regulations.


Acknowledgment of Receipt of this Notice

You will be asked to provide a signed acknowledgment of receipt of this notice. Our intent is to make you aware of the

possible uses and disclosures of your protected health information and your privacy rights. The delivery of your health care service will in no way be conditioned upon your signed acknowledgment. If you decline to provide a signed acknowledgment, we will continue to provide you treatment, and will use and disclose your protected health information for treatment, payment, and health care operations when necessary.


Understanding Your Health Record/Information

Each time you visit Coppola Physical Therapy, a record of your visit is made. Typically, this record contains your

symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, and serves as a:


• Basis for planning your care and treatment,

• Means of communication among the many health professionals who contribute to your care,

• Legal document describing the care you received,

• Means by which you or a third-party payer can verify that services billed were actually provided,

• A tool in educating health professionals,

• A source of data for medical research,

• A source of information for public health officials charged with improving the health of this state and the nation,

• A source of data for our planning and marketing,

• A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve,


Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.


Your Health Information Rights

Although your health record is the physical property of Coppola Physical Therapy, the information belongs to you. You have the right to:


• Obtain a paper copy of this Notice of Privacy Practices upon request,

• Inspect and obtain a copy your health record as provided for in 45 CFR 164.524,

• Request to Amend your health record as provided in 45 CFR 164.528,

• Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528,

• Request communications of your health information by alternative means or at alternative locations,

• Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522, and,

• Revoke your authorization to use or disclose health information except to the extent that action has already been taken.


Our Responsibilities

Coppola Physical Therapy is required to:

1. Maintain the privacy of your health information,

2. Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and

maintain about you,

3. Abide by the terms of this notice,

4. Notify you if we are unable to agree to a requested restriction,

5. Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative location, and

6. Obtain your written authorization to use or disclose your health information for reasons other than those listed above and

permitted under law.


Coppola Physical Therapy, reserves the right to change our privacy information practices and to make the new provisions effective for all protected health information we maintain. Revised notices will be available to you at this office duri ng business hours, or by mail if requested. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.


Examples of How Coppola Physical Therapy, May Use or Disclose Your Health Information


For Treatment: Coppola Physical Therapy, may use your health information to provide you with medical treatment or services. For example, information obtained by a health care provider, such as a physician, nurse, or other person providing health services to you, will record information in your record that is related to your treatment. This information is necessary for health care providers to determine what treatment you should receive. Health care providers will also record actions taken by them in the course of your treatment and note how you respond to those actions.


For Payment: Coppola Physical Therapy, may use and disclose your health information to others for purposes of receiving payment for treatment and services that you receive. For example, a bill may be sent to you or a third-party payor, such as an insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment.


For Health Care Operations: For example, members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.


Appointments: Coppola Physical Therapy, may use your information to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to the individual.


Business Associates: Some services provided in our organization are provided through business associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, or a copy service we may use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.


Directory: Unless you notify us that you object, we may use your name, if you have been transported to a hospital or other facility, and give your general condition, and religious affiliation for directory purposes. This information may be provided to family members or members of the clergy and, except for religious affiliation, to other people who ask for you by name.


Notification, Or Communication With Family Members: Health professionals, using their best judgment, may use, or disclose information to notify or assist in notifying family relatives, personal representatives, close personal friends, or other people you identify; information relevant to that persons’ involvement in your care or payment information related to your care.


Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.


Funeral Directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.

Organ Procurement Organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant


Marketing: We may contact you to provide appointment reminders, information about treatment alternatives or other health-related benefits and services that may be of interest to you.


Fund Raising: We may contact you as part of a fund-raising effort.


Food And Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.


Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.


Public Health: Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, or disability, or for other health oversight activities.


Required By Law: Coppola Physical Therapy, may use and disclose information about you as required by law. For example, Coppola Physical Therapy, may disclose information for the following purposes: for judicial and administrative proceedings pursuant to legal authority; to report information related to victims of abuse, neglect or domestic violence; and to assist law enforcement officials in their law enforcement duties. Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.


Health And Safety: Your health information may be disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.


Government Functions: Specialized government functions such as protection of public officials or reporting to various branches of the armed services that may require use or disclosure of your health information.


For more information, to report a problem, or if you have questions and would like additional information, you may contact our practice’s Privacy Official.


Coppola Physical Therapy

171 Pleasant Street, Suite 101

Concord, NH 03301

Phone: 603-228-7500

Fax: 603-228-3503


If you believe your privacy rights have been violated, you can file a complaint with the practice’s Privacy Officer, or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. The address for the OCR is listed below:


Office for Civil Rights - U.S. Department of Health and Human Services

200 Independence Avenue, S.W. Room 509F, HHH Building Washington, D.C. 20201

866-OCR-PRIV (866-627-7748) or 886-788-4989 TTY