Privacy Policy

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.

Advanced Physical Therapy & Sports Medicine/Advanced Physical Therapy Associates/Advanced Wellness & Physical Therapy/PT Associates of Portage County (APTSM/PTA) is required by federal and state law to maintain the privacy of your health information. 

APTSM/PTA is also required to provide you with a notice that describes APTSM/PTA’s legal duties and privacy practices and your privacy rights with respect to your health information. We will follow the privacy practices described in this notice. 

If you have any questions about any part of this Notice or if you want more information about the privacy practices of APTSM/PTA, please contact the Compliance Officer at 2105 E Enterprise Ave, Suite 113, Appleton, WI 54913.

The following categories describe the ways that APTSM/PTA may use and disclose your health information without your authorization. For each type of use and disclosure, we will explain what we mean and give some examples. 

1. Required by law: We may use and disclose your health information when that use or disclosure is required by law. For example, we may disclose medical information to report child abuse or to respond to a court order. 
2. Public Health: We may release your health information to local, state, or federal public health agencies subject to the provisions of applicable state and federal law for reporting communicable diseases, aiding in the prevention or control of certain diseases, and reporting problems with products. 
3. Victims of Abuse, Neglect or Violence: We may disclose your information to a government authority authorized by law to receive reports of abuse, neglect, or violence relating to children or the elderly. 
4. Health Oversight Activities: We may disclose your health information to health agencies authorized by law to conduct audits, investigations, inspections, licensure, and other proceedings related to oversight of the health care system. 
5. Judicial and Administrative Proceedings: We may disclose your health information in the course of an administrative or judicial proceeding in response to a court order. Under most circumstances when the request is made through a subpoena, a discovery request, or involves another type of administrative order which meets conditions for disclosure. 
6. Law Enforcement: we may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, or missing person, or complying with a court order or other law enforcement purposes. 
7. Coroners and Medical Examiners: We may disclose your health information to coroners and medical examiners. For example, this may be necessary to determine the cause of death. 
8. Cadaveric, Organ, Eye, or Tissue Donation: We may disclose your health information in connection with certain types of organ donor programs. 
9. Research: Under certain circumstances, we may use or disclose your health information to help conduct medical research which may involve an assessment of how well FM-Tips is working. 
10. To Avert a Serious Threat to Health or Safety: We may disclose your health information in a very limited manner to appropriate people to prevent a serious threat to the health or safety of a particular person or the general public. Disclosure is usually limited to law enforcement personnel who are involved in protecting public safety. 
11. Specialized Government Functions: Under certain and very limited circumstances, we may disclose your health care information for military, national security or law enforcement custodial situations. 
12. Workers’ Compensation: Both state and federal law allow the disclosure of your health care information that is reasonably related to a worker’s compensation injury to be disclosed without your authorization. These programs may provide benefits for work-related injuries or illnesses. 
13. Health Information: We may use or disclose your health information to provide information to you about treatment alternatives or other health-related benefits and services that may be of interest to you.

Except as described in the Notice of Privacy Practices, we will not use or disclose your health information without written authorization from you. For example, the sale of protected health information and uses and disclosures made for the purpose of marketing require your authorization. 

If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. 

If you revoke your authorization, we will no longer be able to use or disclose health information about you for the reasons covered by your written authorization, though we will be unable to take back any disclosures we have already made with your permission.

1.  Inspect and Copy Your Health Information: 

• You have the right to inspect and obtain a copy of your health care information. 
• You have the right to review and/or have copies made in an electronic format. 
• Your request for inspection or access must be submitted in writing to the Compliance Officer at 2105 E Enterprise Ave, Suite 113, Appleton WI 54913. 
  • In addition, we may charge you a reasonable fee to cover our expenses for copying your health information. 

2.  Request to Correct Your Health Information:

• You have the right to request that APTSM/PTA amend your health information that you believe is incorrect or incomplete. For example, if you believe the date of your knee surgery is incorrect, you may request that the information be corrected. 
• We are not required to change your health information and if your request is denied, we will provide you with information about our denial and how you can disagree with a denial. 
• To request an amendment, you must make your request in writing to the Compliance Officer at 2105 E Enterprise Ave, Suite 113, Appleton WI 54913.
  
  • You must also provide a reason for your request. 

3.  Request Restriction on Certain Uses and Disclosures:

• You have the right to request restrictions on how your health information is used or to whom your information is disclosed, even if the restriction affects your treatment or our payment or health care operation activities. For example, if you are an employee in a clinic and you receive health care services in that clinic, you may request that your medical record not be stored with the other clinic records.
  
  • However, we are not required to agree in all circumstances to your requested restrictions, except in the case of a restriction of disclosure to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and the protected health information pertains solely to a health care item or service for which you or the person other than the health plan on your behalf, has paid Advanced Physical Therapy & Sports Medicine in full.
• If you would like to make a request for restrictions, you must submit your request in writing to the Compliance Officer at 2105 E Enterprise Ave, Suite 113, Appleton WI 54913.
  
  • A restriction cannot be applied to your health information that has already been disclosed. 

4.  Receive Confidential Communications of Health Information:

• You have the right to request that we communicate your health information to you in different ways or places. For example, you may wish to receive information about your health status in a special, private room or through a written letter sent to a private address. We must accommodate reasonable requests. 
• To receive confidential communications, you must submit your request in writing to the Compliance Officer at 2105 E Enterprise Ave, Suite 113, Appleton WI 54913. APTSM/PTA may communicate with you via email, text, or other electronic means.
  
  • There are risks associated with these types of communications, for example, risks to your confidentiality, and if you are not comfortable with these risks, you should not communicate with APTSM/PTA or its providers via these forms of communication. 

5.  Receive a Record of Disclosures of Your Health Information:

• You have the right to request a list of the disclosures of your health information that we have made in compliance with federal and state law. This list will include the date of each disclosure, who received the disclosed health information a brief description of the health information disclosed, and why the disclosure was made. For some types of disclosures, the list will also include the date and time the request for disclosure was received and the date and time the disclosure was made. For example, you may request a list that indicates all the disclosures your healthcare provider has made from your healthcare record in the past six months. 
• To request this accounting of disclosures, you must submit your request in writing to the Compliance Officer at 2105 E Enterprise Ave, Suite 113, Appleton WI 54913.
  
  • We must comply with your request for a list within 60 days unless you agree to a 30-day extension, and we may not charge you for the list unless you request such a list more than once per year. 

6.  Obtain a Paper Copy of This Notice:

• Upon your request, you may at any time receive a paper copy of this notice, even if you earlier agreed to receive this notice electronically. T
• o obtain a paper copy of this Notice, send a written request to the Compliance Officer at 2105 E Enterprise Ave, Suite 113, Appleton WI 54913.
  
  • This Notice is also available on our website to review, advancedptsm.com. 

7.  Notice of a Breach:

• Your provider is required by law to maintain the privacy of protected health information and provide you with notice of its legal duties and privacy practices with respect to protected health information and to notify you following a breach of unsecured protected health information that qualifies under the federal healthcare privacy rules. 

8.  Complaint:

• If you believe your privacy rights have been violated, you may file a complaint with the Compliance Officer, 2105 E Enterprise Ave, Suite 113, Appleton, WI 54913, will provide you with any needed assistance. 
• We request that you file your complaint in writing so that we may better assist in the investigation of your complaint.
  
  • You may also file a complaint with the Secretary of the Department of Health and Human Services (DHHS). 
  • There will be no retaliation against you in any way for filing a complaint. 

9.  Fundraising: We may contact you for fundraising purposes or have someone contact you on our behalf. You have a right to opt out of fundraising communications and can do so in writing to the Compliance Officer, 2105 E Enterprise Ave, Suite 113, Appleton, WI 54913, or by calling the Compliance Officer at 920-991- 2561 with your instructions to opt out of fundraising communications.

If you have any questions or concerns regarding your privacy rights or the information in this notice please contact:

Compliance Officer

2105 E Enterprise Ave, Suite 113

Appleton, WI 54913

Effective Date of this Notice: May 15, 2023

**Please note: We reserve the right to change the privacy practices described in this notice if the practices need to be changed to follow the law. We will make the new notice provisions effective for all the protected health information that we maintain. If we change our privacy practices, we will have them available upon request. This notice will also be posted at the location of service.