Notice of Privacy Practices
10-1-04
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.

I. Who We Are
This Notice describes the privacy practices of Tennessee Sports Medicine, members of its workforce and the physician members of its medical staff. It applies to services furnished to you at the site of athletic participation or any location by Tennessee Sports Medicine employed certified athletic trainers, affiliated physicians, business associates and other staff and volunteers of our organization who participate in the Sports Medicine program (“we” or “us”).

II. Our Privacy Obligations
We are required by law to maintain the privacy of your health information (“Protected Health Information” or “PHI”) and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure

III. Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which we will describe in Section IV below, we must obtain your written authorization in order to use and/or disclose your PHI. However, we do not need any type of authorization from you for the following uses and disclosures:
A. Uses and Disclosures For Treatment, Payment and Health Care Operations. We may use and disclose PHI, but not your “Highly Confidential Information” (defined in Section IV.C below), in order to treat you, obtain payment for services provided to you and conduct our “health care operations” as detailed below:
• Treatment. We use and disclose your PHI to provide treatment and other services to you - for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also disclose PHI to other providers involved in your treatment, including appropriate school coaches and administrators.
• Payment. We may use and disclose your PHI to obtain payment for services that we provide to you - for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care (“Your Payor”) to verify that Your Payor will pay for health care.
• Health Care Operations. We may use and disclose your PHI for our health care operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use PHI to evaluate the quality and competence of our physicians, nurses and other health care workers. We may disclose PHI to our Patient Relations Coordinator in order to resolve any complaints you may have and ensure that you have a comfortable visit with us.
We may also disclose PHI to our business associates for treatment, payment of health care operations, or to your other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.
B. Disclosure to Relatives, Close Friends and Other Caregivers. We may use or disclose your PHI to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure.
If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the person’s involvement with your health care or payment related to your health care. We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.
C. Other Uses Not Requiring Your Written Authorization. Subject to certain requirements, we may give out medical information about you without prior authorization for public health activities, victims of abuse, neglect or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement officials, decedents, organ and tissue procurement, research, health or safety, specialized government functions, worker’s compensation, and as required by law.

IV. Uses and Disclosures Requiring Your Written Authorization. For any purpose other than the ones described above in Section III, we may only use or disclose your PHI when you grant us written authorization. We must also obtain written authorization prior to using your PHI for marketing purposes or before using “highly confidential information.”

V. Your Rights Regarding Your Protected Health Information
A. For Further Information, Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact our Privacy Office. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Office will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.
B. Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions, please obtain a request form from our Privacy Office and submit the completed form to the Privacy Office. We will send you a written response.
C. Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable [written] request for you to receive your PHI by alternative means of communication or at alternative locations.
D. Right to Revoke Your Authorization. You may revoke Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Privacy Office identified below. [A form of Written Revocation is available upon request from the Privacy Office.]
E. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from the Privacy Office and submit the completed form to the Privacy Office. If you request copies, we will charge a fee for each page. We will also charge you for our postage costs, if you request that we mail the copies to you.
F. Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please obtain an amendment request form from the Privacy Office and submit the completed form to the Privacy Office. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
G. Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, we will charge a fee per page of the accounting statement.
H. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.

VI. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective on April 14, 2003.
B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in waiting areas around Tennessee Sports Medicine, on our web site at www.tennesseesportsmed.com or you may contacting our office at 615-443-7700. You also may obtain any new notice by contacting the Privacy Office.

VII. Privacy Office
You may contact the Privacy Office at:

Privacy Office
c/o Tennessee Sports Medicine
1430 Baddour Parkway, Ste. A
Lebanon, Tennessee 37087