620 W. Cheyenne Drive
Evanston, WY 82930
Phone: (307) 789-8860
Fax: (307) 789-8394

64 Meadow Street (Urie Mall)
Urie, WY 82937
Phone: (307) 786-4460
Fax: (307) 786-4461
Wyoming Specialized Physical Therapy

Effective: June 25, 2003

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.

Our Privacy Responsibilities
Wyoming Specialized Physical Therapy is required by law to:
  • Maintain the privacy of your health information;
  • Provide this notice that describes the ways we may use and share your health information; and
  • Follow the terms of the notice currently in effect.
We reserve the right to make changes to this notice at any time and make the new privacy practices effective for all information we maintain. Current notices will be posted in Wyoming Specialized Physical Therapy facilities. You may also request a copy of any notice from Wyoming Specialized Physical Therapy Privacy Office.

Your Individual Rights
You have the right to:
  • Request restriction on how we use and share your health information. We will consider all requests for restrictions carefully but are not required to agree to any restriction.
  • Request that we use a specific telephone number or address to communicate with you.
  • *Request corrections or additions to your health information.
  • *Request an accounting of certain disclosures of your health information made by us The accounting does not include disclosures made for treatment, payment, and health care operations and some disclosures required by law. Your request must state the period of time desired for the accounting, which must be within the six years prior to you request and exclude dates prior to June 25, 2003. The first accounting is free, but a fee will apply if more than one request is made within a 12-month period.
Requests marked with a star (*) must be made in writing. Contact the Wyoming Specialized Physical Therapy Privacy Office for the appropriate form for your request.

Our Organization
This notice describes the privacy practices of Wyoming Specialized Physical Therapy, as well as the Wyoming Specialized Physical Therapy employees and volunteers at those facilities. This notice also describes the privacy practices of affiliated providers while they are performing services in a Wyoming Specialized Physical Therapy facility, unless they provide you with a notice of their specific privacy practices. Affiliated providers are not employed by Wyoming Specialized Physical Therapy but are either authorized to provide services to patients in a Wyoming Specialized Physical Therapy facility or are approved participants on the panel of Wyoming Specialized Physical Therapy Health Plans' Providers.

Contact Us
If you would like further information about your privacy rights, are concerned that your privacy rights have been violated, or disagree with a decision that we made about access to your health information.

Contact the privacy coordinator, Michael Jacketta, MPT at (307) 789-8860

We will investigate all complaints and will not penalize or treat you any differently for filing a complaint. You may also file a written complaint with the Office of Civil Rights of the US Department of Health and Human Services.

Privacy Promise
Wyoming Specialized Physical Therapy understands that your medical and health information is personal. Protecting your health information is important. We follow strict federal and state laws that require us to maintain the confidentiality of your health information.

How We Use Your Health Information
When you receive care from Wyoming Specialized Physical Therapy, we may use your health information for treating you, billing for services, and conducting our normal business (known as "health care operators"). Examples of how we use your information include:

Treatment - We keep records of the care and services provided to you. Health care providers use these records to deliver quality care to meet your needs. For example, your doctor may share your health information with a specialist who will assist in your treatment. Some health records, including some confidential communications with a medical health professional, some substance abuse treatment records, some genetic test results, and some health information of minors, may have additional restrictions for use and disclosure under state and federal laws.

Payment - We keep billing records that include payment information and documentation of the services provided to you. Your information may be used to obtain payment from you, your insurance company, or other third party. We also may contact your insurance company to verify coverage for your care or to notify them of upcoming services that may need prior notice or approval. For example, we may disclose information about the services provided to you to claim and obtain payment for your insurance company or Medicare.

Health Care Operations - We use health information to improve the quality of care, train staff and students, provide customer service, manage costs, conduct required business duties, and make plans to better serve our communities. For example, we may use your health information to evaluate the quality of treatment and services provided by our physicians, nurses, and other health care workers.

Other Services We Provide
We may also use your health information to:
  • Recommend treatment alternatives;
  • Tell you about health services and products that may benefit you;
  • Share information with family and friends involved in your care or payment for your care, when appropriate;
  • Share information with third parties who assist us with treatment, payment and health care operations. Our business associates must protect your information by following our privacy practices;
  • Remind you of and appointment (if you do not wish to be reminded, notify the scheduler)
Sharing Your Health Information
There are limited situations when we are permitted or required to disclose health information without your signed authorization. These situations are:
  • For public health purposes such as reporting communicable diseases, work-related illnesses, or other diseases and injuries permitted by law; reporting births and deaths; and reporting reactions to drugs and problems with medical devices;
  • To protect victims of abuse, neglect, or domestic violence;
  • For health oversight activities such as investigations, audit, and inspections;
  • For lawsuits and similar proceedings;
  • When otherwise required by law;
  • When requested by law enforcement as required by law or court order;
  • To coroners, medical examiners, and funeral directors;
  • For organ and tissue donation;
  • For research approved by our review process under strict federal guidelines;
  • To reduce or prevent a serious threat to public health and safety;
  • For workers' compensation or other similar programs if you are required at work;
  • For specialized government functions such as intelligence and national security.
All other uses and disclosures, not described in this notice, require your signed authorization. You may revoke your authorization at any time with a written statement.
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