Horizon Therapy, LLC

604 Pebble Beach Ct Martinez, GA 30907

NOTICE OF PRIVACY PRACTICES
This Notice of Privacy Rights and Practices is provided to you as a requirement of the Heath
Insurance Portability and Accountability Act (HIPPA). It describes how your health
information may be protected and disclosed in order to carry out treatment, payment, or
health care operations and for other purposes that are permitted or required by law. This
notice also describes your rights to access and/or refuse the release of specific information
with the exception of when the release is required or authorized by law/regulation.
The law requires that I protect the privacy of protected health information, and to provide
you with a copy of this Notice, which describes my legal duties and privacy practices with
respect to protected health information.
Acknowledgement of Receipt of this Notice
You will be asked to provide a signed acknowledgement of receipt of this notice. The intent
is to make you aware of the possible uses and disclosures of your/your childs protected
health information and privacy rights. The delivery of your or your childs health care
services will in no way be conditioned upon your signed acknowledgement.
Responsibility Regarding Protected Health Information
Protected health information is individually identifiable health information. This includes
demographics such as age, address, email address, and relates to past, present, or future
physical/mental health or condition and related health care services. We are required by law
to do the following:
Ensure protected health information is kept private
Provide you with this notice of our legal duties and privacy practices related to the
use and disclosure of protected health information
Follow the terms of this notice currently in effect
Communicate any changes of this notice to you
Horizon Therapy, LLC reserves the right to change this notice with a New Notice. We
reserve the right to make the revised or changed notice effective for health information we
are already in possession of, as well as any information received in the future. We are
required to abide by the terms of this notice until the New Notice becomes effective. You
may request a copy at any time.

Uses and Disclosures of Health Information

Horizon Therapy uses and discloses your health information for treatment, payment, and
healthcare operations.
Treatment: I may use or disclose your health information to provide, coordinate, or manage
health care with any related service to include a physician or other healthcare provider
providing treatment to you/your child.
Payment: I may use or disclose medical information about you so that the treatment and
services you received may be billed to and payment may be collected from you, and
insurance company, or a third party. I may also use and disclose medical information about
you to obtain prior approval or to determine whether you are insurance will cover treatment.
Healthcare Operations: I may use and disclose your health information in connections with
our healthcare operations. Healthcare operations include quality access and many
improvement activities; such as, reviewing the competence or qualifications of healthcare
professionals, evaluating practitioner and provider performance, conduction of training
programs for healthcare professionals, accreditation, certification, licensing or credentialing
activities.
Your Authorization: In addition to our use of your health information for treatment,
payment, or healthcare operations, you may give written authorization to use or disclose
your information to anyone for any purpose. If you give me an authorization, you may
revoke it in writing at any time. Your revocation will not affect any use or disclosures
permitted by your authorization while it was in effect. Unless you give us a written
authorization, I cannot use or disclose your health information for any reason except those
described in this notice.
To Your Family and Friends: I must disclose your health information to you, as described in
the Patient Rights section of this Notice. I may disclose health information to a family
member, friend, or other person to the extent necessary to help with your/your childs
healthcare or with payment for your healthcare, but only if you agree that I may do so.
Persons Involved in Care: I may use or disclose health information to notify, or assist in the
notification of (including identifying or location) a family member, your personal
representative or another person responsible for your care, of your location, your general
condition, or death; if you are present. Then prior use of disclosure of your health
information, I will provide you with an opportunity to object to such uses or disclosures. In
the event of your incapacity or emergency, I will provide you with an opportunity to object
to such uses or disclosures. In the event of your incapacity or emergency circumstances, I
will disclose your/your childs health information based on a determination using my
professional judgment disclosing only health information that is directly relevant to the
persons involvement in your healthcare. I will also use my professional judgment and my
experience with common practice to make reasonable interferences of your/your childs best
interest in allowing that person to pick up progress notes, evaluations, and/or other similar
forms of health information.
Marketing Health-Related Services: I will not use your health information for marketing
communication without your written permission.
Appointment Reminders: I may use or disclose your health information to provide you with
appointment reminders (such as voicemail messages, postcards, or letters).

Required by Law: I may use or disclose your health information if and when I am required to
do so by law:
Abuse or Neglect: I may disclose your health information to appropriate authorities if I
reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or any
other crimes. I may disclose you information to the extent necessary to avert a serious threat
to your health, or safety of others.
National Security: I may disclose to military authorities the health information of Armed
Forces personnel under certain counterintelligence, and other national security activities. I
may disclose to correctional institution or law enforcement officials having lawful custody of
protected health information of patient under certain circumstances.
Health Oversight: I may use or disclose your health information to a health oversight agency
for activities authorized by law, such as audits, investigations, and inspections. These health
oversight agencies may include government agencies that oversee the health care system,
government benefit programs, other government regulatory programs, and civil rights laws.
Legal Proceedings: I may use or disclose protected health information during any judicial or
administrative proceeding, in response to a court order or administrative tribunal, and in
certain conditions in response to a subpoena, discovery request, or other lawful process.
Patient Rights
You may exercise the following rights by providing a written request to Horizon Therapy,
LLC.
Right to Inspect and Copy: You have the right to inspect and copy medical information that
may be use to make decisions about your care. Usually, this includes medical and billing
records.
Right to an Accounting Disclosure: You have the right to request an accounting of
disclosures. This is a list of certain disclosures I made of medical information about you for
the last 6 years, but not before April 14th, 2003*. This right excludes disclosures made to

you or authorized by you to family members or friends involved in your/your childs care, or
for notification. The right to receive this information is subject to additional exceptions,
restrictions, and limitations as described earlier in this notice.
Right to Request Restrictions: You have the right to request a restriction or limitation on the
medical information I use or disclose about you to someone who is involved in your care for
the payment for your care, like family member or friend. I am not required to agree to your
request. If I do agree, I will abide by our agreement (except in emergency).
Right to Alternative Communication: You have the right to request that I communicate with
you about your health information by alternative means or to alternative location (You must
make your request in writing). Your request must specify the alternative means or location
you request.
Right to Amend: You have the right to request that I amend your health information. I may
deny your request under certain circumstances.
Right to a Paper Copy of this Notice: You have the right to a paper copy of this notice at
any time. To obtain a paper copy of this notice, please request on in writing from the contact
information listed at the end of this Notice.
*Effective April 14th, 2003 a new federal law called the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) went into effect

Complaints
If you believe these privacy rights have been violated, you may file a written complaint with
the Department of Health and Human Services. No retaliation will occur against you for
filing a complaint.

ACKNOWLEDGEMENT FORM
I have received the Notice of Privacy Practices and I have had the opportunity to
review it.
Patient Name: ____________________________ Patient DOB:_____________________
Parent Name: ____________________________________________________________
Parent Signature:__________________________________________________________
Todays Date: _________________________