NOTICE OF PRIVACY
The staff of Omni Physical Therapy LLC has always protected the confidentiality of health information by
sealing medical records away in file cabinets and refusing to reveal your health information without your
consent. Now state and federal laws also attempt to ensure the confidentiality of this sensitive information.
This Notice of Privacy will inform you of our privacy practices and your rights. Our practices and your
rights are as follows.
1.
All staff have been trained to maintain confidentiality of your medical records.
2.
If you are a parent or guardian of a minor, you have a right to the health record of the minor.
3.
You have the right to limit who among family has access to your record by telling us who can
receive such information by filling out the section below for this purpose. In the event that you choose
not to limit access by family, leave the section below blank.
4.
The law allows us to use your patient information for treatment, payment and administrative
proposes without your written consent.
5.
You have a right to your medical record at any time by filling out a form available from the
receptionist. It is customary that a nominal fee be assesses for copying services.
6.
The law does allow treating staff to discuss your treatment without your consent.
7.
Your record is safeguarded from exposure to casual workers entering the office such as delivery
and service personnel.
8.
We will make every effort to ensure a confidential space for sensitive conversations
between you and our staff.
These rules are to ensure your privacy while under our care. If you have any questions, concerns, or
comments about this Notice of Privacy, please contact: Hunter Knight, PT, our designated privacy
officer, at 314-775-0183.
I have read and understand the above statements and I authorize release of my medical record to any of my
immediate family.
Patient or parent/guardian signature ___________________________Date___________
Limited Family Access to the Medical Records
I want to exercise my right to limit access to my medical records by my family. Listed below are the family
members I want to have access to my medical record:
___________________
_____________________
___________________
_____________________
___________________
_____________________
Patient or parent/guardian signature ___
_________________________Date__________
NO Family Access to the Medical Records
I do not want any of my family to have access to my medical record.
Patient or parent/guardian signature ____________________________Date__________
Omni Physical Therapy LLC. will be happy to comply with your request. This document will be
made a part of your permanent record unless you give us different instructions
