Caze Concussion Institute, LLC.
Effective Date: August 3, 2022
This Notice Describes How Health Information About You May Be Used And
Disclosed And How You Can Get Access To This Information
Please Review It Carefully
If you have any questions about this Notice, please contact our Privacy Officer Todd Caze at (402) 577-0292.
This Notice Applies To:
Caze Concussion Institute, LLC, its employees and independent contractors. This Notice describes our privacy
Our Pledge Regarding Health Information:
We understand that health information about you and your health care is personal. We are committed to protecting
your health information about you. We create a record of the care and services you receive from us. We need this record to
provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records
of your care generated by this health care practice, This Notice will tell you about the ways in which we may use and
disclose health information about you. We also describe your rights to the health information we keep about you, and
describe certain obligations we have regarding the use and disclosure of your health information.
We are required to:
• maintain the privacy and security of protected health information;
• make available to you this Notice which describes our legal duties and privacy practices with respect to your
• abide by the terms of this Notice;
• notify you if we are unable to agree to a requested restriction on how your information is used or disclosed;
• notify you of any breach of your unsecured protected health information;
• accommodate reasonable requests you may make to communicate health information by alternative means or at
• obtain your written authorization to use or disclose your health information for reasons other than those listed
above and permitted under law;
• make sure that health information that identifies you is kept private; and
• give you this Notice of our legal duties and privacy practices with respect to health information about you.
How We May Use And Disclose Health Information About You:
The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment: We may use health information about you to provide you with health care treatment or services. We may disclose health information about you to your occupational or physical therapists, personal trainers, doctors, nurses, technicians, health students, or other personnel who are involved in taking care of you. They may work at our offices, at the hospital if you are hospitalized, or at another doctor’s office, lab, pharmacy, occupational therapy or 24862-7806-2886.2 physical therapy provider, or other health care provider to whom we may refer you for consultation, to take x-rays, to perform lab tests, to have prescriptions filled, or for other treatment purposes.
For Payment: We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about your visit so your health plan will pay us or reimburse you for the visit. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. For Health Care Operations: We may use and disclose health information about you for the operations of our business. These uses and disclosures are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use and disclose health information in an accounting audit of our practice. We may use and disclose health information to business associates or organized healthcare arrangements or accountable care organizations. We may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide what additional services we should offer, what services are not needed, whether certain new treatments are effective, or to compare how we are doing with others and to see where we can make improvements. We may remove information that identifies you from this set of health information so others may use it to study health care delivery without learning who our specific patients are.
Health-Related Services and Treatment Alternatives: We may use and disclose health information to tell you about health-related services or recommend possible treatment options or alternatives that may be of interest to you. Please let us know if you do not wish us to send you this information, or if you wish to have us use a different address to send this information to you.
Research: Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one treatment with those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with patients’ need for the privacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process; but we may disclose health information about you to people preparing to conduct a research project. For example, we may help potential researchers look for patients with specific health needs, so long as the health information they review does not leave the facility.
As Required By Law: We will disclose health information about you when required to do so by federal, state, or local law.
To Avert a Serious Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosures, however, would only be to someone able to help prevent the threat.
Military and Veterans: If you are a member of the armed forces or separated/discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans Affairs as may be applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities.
Workers’ Compensation: We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks: We may disclose health information about you for public health activities. These activities
generally include the following:
• to prevent or control disease, injury or disability;
• to report birth and deaths;
• to report child abuse or neglect;
• to report reactions to medications or problems with products;
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease
or condition; and
• 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.
Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government 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 health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or another lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement: We may release health information if asked to do so by a law enforcement official:
• in reporting certain injuries, as required by law, such as gunshot wounds, burns, injuries to perpetrators of crime;
• in response to a court order subpoena, warrant, summons or similar process;
• to identify or locate a suspect, fugitive, material witness, or missing person:
− Name and address
− Date of birth or place of birth;
− Social security number;
− Blood type or rh factor;
− Type of injury;
− Date and time of treatment and/or death, if applicable; and
− A description of distinguishing physical characteristics;
• about the victim of a crime, if the victim agrees to disclosure or 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 our facility; 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.
Coroners, Health Examiners and Funeral Directors: We may release health information to a coroner or health examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities: We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others: We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health 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 and safety of others; or (3) for the safety and security of the correctional institution.
Specific Disclosures Which Require Authorization Under HIPAA:
Uses and Disclosures You Specifically Authorize: You may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. If you give us authorization, you may revoke it in writing at any time. If you revoke your permission, we will stop using or disclosing your protected health information in accordance with that authorization, except to the extent we have already relied on it. Without your written authorization, we may not use or disclose your protected health information for any reason except those described in this Notice.
Psychotherapy Notes: HIPAA requires a provider which maintains psychotherapy notes to obtain authorization for any use or disclosure of psychotherapy notes, except in limited circumstances as provided in 45 C.F.R. §164.508(a)(2). We do not maintain or want any psychotherapy notes.
Marketing: We must obtain authorization for any use or disclosure of protected health information for marketing (as defined under HIPAA), except if the communication is in the form of a face-to-face communication made by us to an individual; or a promotional gift of nominal value provided by us. If the marketing involves financial remuneration, as defined in paragraph (3) of the definition of marketing at 45 C.F.R. §164.501, to us from a third party, the authorization must state that such remuneration is involved.
Sale of Protected Health Information: Except in limited circumstances covered by the transition provisions in 45 C.F.R. §164.532, we must obtain authorization for any disclosure of protected health information which is a sale of protected health information, as defined in 45 C.F.R. §164.501. Such authorization must state that the disclosure will result in remuneration to the covered entity.
Your Rights Regarding Health Information About You:
You have the following rights regarding the health information we maintain about you:
Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes health and billing records. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies and services associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by our practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to Amend: If you feel that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we keep the information. To request an amendment, your request must be made in writing, submitted to our Privacy Officer, and must be contained on one page of paper legibly handwritten or typed in at least 10-point font size. In addition, you must provide a reason that supports your request for an amendment.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
• was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• is not part of the health information kept by or for our practice;
• is not part of the information which you would be permitted to inspect and copy; or
• is accurate and complete.
Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.
Right to an Accounting of Disclosures: You have the right to request a list accounting for any disclosures of your
health information we have made, except for uses and disclosures for treatment, payment, and health care operations,
as previously described.
To request this list of disclosures, you must submit your request in writing to the Privacy Officer. Your request must
state a time period which may not be longer than six (6) years prior to the date of the request. The first list you request
within a twelve (12) month period will be free. For additional lists, we may charge you for the costs of providing the
list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time
before any costs are incurred. We will mail you a list of disclosures in paper form within thirty (30) days of your
request, or notify you if we are unable to supply the list within that time period and by what date we can supply the
list; but this date will not exceed a total of sixty (60) days from the date you made the request.
Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we
use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit
on the health information we disclose about you to someone who is involved in your care or the payment for your
care, such as a family member or friend. For example, you could ask that we restrict a specified nurse from use of
your information, or that we not disclose information to your spouse about a surgery you had.
We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively impact the care we may provide you (except in the case of disclosure protected under 45 C.F.R. § 164.522(a)(1)(vi)). If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request a restriction, you must make your request in writing to the Privacy Officer. In your request, you must tell us what information you want to limit and to whom you want the limit to apply; for example, use of any information by a specified nurse, or disclosure of specified surgery to your spouse.
Right to Restrict Disclosure to Health Plans: You have the right to prohibit us from disclosing to your health plan personal information related to a particular service if you pay us for that service upfront and in full.
Right to Request Confidential Communications: You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail to a post office box. To request confidential communications, you must make your request in writing to the Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
Right to Electronic Copy of “Electronic Health Record: If we maintain your “Electronic Health Record,” you have the right to ask for an accounting of disclosures of where we disclosed your health information. You may request an accounting for a period of three years prior to the date the accounting is requested. You also have the right to ask our business associates for an accounting of their disclosures. In addition, if you have an “Electronic Health Record” with us, you have a right to request an electronic copy of your Electronic Health Record. Not all healthcare information stored electronically is considered an Electronic Health Record. The term ‘‘Electronic Health Record’’ means an electronic record of health-related information on an individual that is created, gathered, managed, and consulted by authorized healthcare clinicians and staff.
Right to Notice of Breach: You have the right to notice of a “Breach” involving any of your “Unsecured health information” as these terms are defined under the law. Not all unauthorized uses or disclosure of your health information will be considered a breach under the law. This notice will be sent as required under the law. If you authorize us to communicate with you by e-mail we may e-mail you notice of any breach. In most other cases we will send you the required notice in writing and by mail.
Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this Notice at any time. To obtain a copy, please request it from the Privacy Officer. You may also obtain a copy of this Notice from our website, www.cazeinstitute.com. Even if you have requested notice electronically, you still retain the right to receive a paper copy upon request.
CHANGES TO THIS NOTICE:
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in our facility. The Notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register for treatment or health care services, we will offer you a copy of the current Notice in effect, and a current copy will be available on our website.
If you believe your privacy rights have been violated, you may file a complaint with us. All complaints must be submitted in writing. You will not be penalized for filing a complaint. You should contact our Privacy Officer as
Caze Concussion Institute, LLC
7100 W Center Rd, Floor 4
Omaha, NE 68106
You may also file a complaint with the Secretary of the Department of Health and Human Services.
OTHER USES OF HEALTH INFORMATION:
Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are not able to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE:
We will request that you sign a separate form or notice acknowledging you have received a copy of this Notice. If you choose, or are not able to sign, a staff member will sign their name and date. This acknowledgement will be filed with your records.
Uses and disclosures of your protected health information are regulated by the federal HIPAA law. This Notice attempts to summarize the Privacy Regulations. The Privacy Regulations will supersede any discrepancy between the information in this Notice and the Privacy Regulations.