NOTICE OF INFORMATION PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION.
Our Responsibilities | We are required by law to safeguard your protected health information, provide this notice, and follow its terms. We will notify you if a breach compromises your information.
Uses and Disclosures | Information may be used or disclosed for treatment, payment, healthcare operations, appointment reminders, public health reporting, and legal requirements as permitted by law.
Substance Use Disorder Records | Certain records relating to substance use disorder treatment receive additional federal protections. When applicable:
- Written consent is required for disclosure related to treatment, payment, or operations
- A single consent may authorize future disclosures
- Counseling notes require separate consent
- Records are restricted from use in legal proceedings without proper authorization
- Redisclosure is governed by federal privacy standards
Educational Use | We may use non-identifying information for educational purposes. Identifying information will not be used without written authorization.
Your Rights | You have the right to inspect records, request corrections, request confidential communications, request disclosure limits, receive an accounting of disclosures, obtain a copy of this notice, and file a complaint.
Complaints | Complaints may be submitted to our office or to the U.S. Department of Health and Human Services without retaliation.
Changes to This Notice | We reserve the right to revise this notice. Updated versions will be available upon request.
NON-DISCRIMINATION POLICY
Active Sports Therapy complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Active Spine and Joint Center does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Active Sports Therapy:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
Qualified interpreters
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages If you need these services, contact Cassie Hulme
If you believe that Active Sports Therapy has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Cassie Hulme, Clinic Administrator, Mail 123 Stadium Drive, Hendersonville, TN 37075, Phone 615-537-5520, Fax 615-537-5521, Email cassie@activesports.care. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Cassie Hulme, Clinic Administrator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
GOOD FAITH ESTIMATE / NO SURPRISES ACT
When we do not have insurance information on file for an upcoming visit, we will provide you with a Good Faith Estimate of the cost of items and services that are reasonably expected for your health care needs and that is based on information known at the time it was created. If you are billed for more than the Good Faith Estimate amount, you have the right to dispute the bill.
You may contact the health care provider or facility listed to let them know that the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date of the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on the Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 1-877-696-6775. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-877-696-6775.
Keep copies of any Good Faith Estimates you receive in a safe place or take pictures of them. You may need them if you are billed a higher amount.
FINANCIAL POLICY
Insurance Verification | Insurance verification is not a guarantee of payment. Coverage estimates are based on information provided by your insurance carrier and may differ from final processing. Charges not covered by insurance remain the patient’s responsibility. Patients are encouraged to verify benefits directly with their insurer.
Deductibles, Copayments, and Coinsurance | Patient financial responsibility is due at the time of service unless other arrangements are made. After insurance processing, any remaining balance will be billed and is due within 30 days.
Outstanding Balances | Balances not paid within 30 days may accrue a finance charge at a rate permitted under Tennessee law. Accounts may be referred to a collection service consistent with applicable regulations after reasonable notice. Disputed balances must be communicated in writing within 30 days of billing.
Returned Payments | Returned checks or failed electronic payments may incur a reasonable processing fee permitted by Tennessee law.
Appointments | We request at least 24 hours notice for cancellations. Repeated missed appointments may result in a reasonable administrative fee intended to offset scheduling costs. Workers’ compensation or personal injury cases may require documentation of missed visits.
Questions | Billing questions may be directed to our office during normal business hours.