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Acknowledgment of Practice Privacy Policy and Designation of Disclosure

1. Acknowledgement of Privacy Practice Notice - I have reviewed a copy of Thryve Healing and Performance’s Notice of Privacy Practices


2. Designation of Certain Relatives, Caregivers, and Close Friends - Thryve Healing and Performance cannot release information regarding your treatment or test results to anyone that is not specifically authorized by you as per the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Persons under the age of 10 may have their information shared with the parent or legal guardian without written consent with the exception of information pertaining to sexually transmitted diseases. Certain medical emergencies may necessitate release of your medical information to someone not listed in this release; information requested in the course of a criminal investigation is not bound to this release.

3. Attention - By completing below, I agree to items I and II above.

Notice of Privacy Practices




This notice describes our Practice’s privacy policies, which extends to:


- All employees, staff and other personnel that work for or with our practice.

- All future acquired personnel of the practice (front desk, administration, etc.)



The practice provides this Notice to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).




We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create records about your health, our care for you, and the services and/or items we provide to you as our patient. We need this record to provide you care and to comply with certain legal requirements.

Law requires us to:


- Make sure that the protected health information about you is kept private.

- Provide you with a Notice of our Privacy Practices and your legal rights with respect to protected health information about you and follow the conditions of the Notice that is currently in effect.




The following categories describe different ways that we may use and disclose protected health information that we have. Each category of use or disclosures provides a general explanation and provides some examples of uses. Not every use or disclosure in a category is either listed or actually in place. The explanation is provided for your general information only.


Medical Treatment: We use previously given medical information about you to provide you with current prospective medical services. Therefore, we may, and most likely will, disclose medical information about you to doctors, nurses, technicians, medical students, or hospital personnel who are involved in taking care of you. For example, a doctor to whom we refer you for ongoing or further care may need your medical records. Different areas of the practice also may share medical information about you including your record(s), prescriptions, requests of lab work and X-Rays. We may also discuss your medical information with you to recommend possible treatment options or alternatives that may be of interest to you. We may also disclose medical information about you to people outside the practice who may be involved in your medical care after you leave the practice; this may include your family members, or other personal representatives authorized by you or your legal mandate (a legal guardian or other person who has been named to handle your medical decisions should you become incompetent).

Payment: We may use and disclose medical information about you for services and procedures so they may be billed and collected from you, an insurance company, or any third party. For example, we may need to give your health care information, about treatment you received at the practice, to obtain payment or reimbursement for the care. We may also tell your health plan and/or referring physician about a treatment you are going to receive to obtain prior approval or to determine whether your health plan will cover the treatment to facilitate payment of the referring physician or the like.


Health Care Operations: Our practice may use and disclose your Protected Health Information (PHI) to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice.


Appointment and Patient Recall Reminders: We may ask that you sign in writing on a “sign In” log on the day of your appointment. We may use and disclose medical information to contact you as a reminder that you have an appointment for medical care with the Practice or that you are due to receive periodic care from the Practice. This contact may be by phone, in writing, e-mail, or otherwise and may involve the leaving of a message on an answering machine, or otherwise which could (potentially) be received or intercepted by others.


Emergency Situations: In addition, we may disclose medical information about you to an organization assisting in a disaster relief effort or in an emergency situation so that your family can be notified about your condition, status and location.


Research: Under certain circumstances, we may use and disclose medical information about you for research purposes regarding medications, efficiency of treatment protocols, and the like. We will obtain an Authorization from you before using or disclosing your individually identifiable health information unless the authorization requirements have been waived in accordance with federal law.


Required by Law: We will disclose medical information about you to governmental or other authorities when required or authorized to do so by federal, state or local law.


To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat either to your specific health and safety or the health of the public or another person.


Organ and Tissue Donation: If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye and tissue transplant or to an organ donation bank, as necessary to facilitate organ or tissue donation transplant.

Workers Compensation: We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work related injuries or illness.


Public Health Risk: Law or public policy may require us to disclose medical information about you for public health activities. These activities generally include the following:

- To prevent or control disease, injury or disability

- To maintain vital records, such as, births and deaths;

- To report child abuse or neglect;

- To notify people of recalls of products they may be using;

- To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease/condition.

- To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

- Notifying your employer under limited circumstances related primarily to workplace injury or illness medical surveillance.


Investigation and Government Activities: We may disclose medical information to a local, example, audits, investigations, inspections, and licensure. These activities are necessary for the payer, the government and other regulatory agencies to monitor the health care system, government programs, and compliance with civil rights laws.


Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court administrative order.


Law Enforcement: We may release medical information if asked to do so by law enforcement official:

- In response to court order, subpoena, warrant, summons or similar process;

  • To identify or locate or suspect, fugitive, material witness, or missing person;

  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;

  • About a death we believe may be the result of criminal conduct;

  • About criminal conduct at the practice; and

  • In emergency circumstances to report a crime; the location of the crime or victims; or the identity,

  • description or location of the person who committed the crime.


Release of Information to Family/Friends: Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.


Military/National Security: Our practice may disclose your PHI if you are a member of US, foreign military forces (including veterans) or federal officials for intelligence and national security activities authorized by law. We may also disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.


Coroners, Medical Examiners and Funeral Directors: We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release information about patients of the Practice to funeral directors as necessary to carry out their duties.


Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health of others; (3) for the safety and security of the correctional institution.


State Law Restrictions: In the case of HIV-Related information, special protections apply under New Jersey law. With certain exceptions, your permission is generally required by law to release information.



We reserve the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we may receive from you in the future. We will post a copy of the current notice in the Practice. The notice will contain on the first page, in the top right-hand corner, the date of the last revision and the effective date. In addition, each time you visit the Practice for the treatment or health care services you may request a copy of the current notice in effect.



If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of the Health and Human Services. 


To file a complaint with our practice, contact Thryve Healing & Performance at All complaints must be submitted in writing. You will not be penalized for filing a complaint.



Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission, unless those uses can be reasonably inferred from the intended uses above. If you have provided us with your permission to use or disclose medical information about you, you may revoke your permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records for the care that we provided to you.

Thryve Healing & Performance may disclose my health information to the person(s) listed below. I understand that I am not required to list anyone. I also understand that I may change this at any time in writing.

Parent or Guardian certifying this statement if under the age of 18.

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