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Notice of Privacy Practices

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.

The Privacy Of Your Health Information Is Important To Us.


We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003 and will remain in place until we are notified of legal changes.

Before we make a significant change in our privacy practices we will change this Notice, make the new Notice available upon request, and display the new Notice in our waiting room.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.


We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare practitioner providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use or disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conduction training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization you may revoke it in writing at any time. Your revocation will not affect any use of disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your personal health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare , but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose your health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required By Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement officials having lawful custody of protected health information of an inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as Voicemail messages, postcards, or letters).



Access: You have the right to look at or obtain copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities, for the last six (6) years, but not before April 14, 2003.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing. Your request must specify the alternative means or location.

Amendment: You have the right to request that we amend your health information. Your request must be in writing and must explain why the information should be amended. We have the right to deny your request under certain circumstances.

Electronic Notice: If you receive this Notice by e-mail, you are entitled to receive this Notice in written form.



If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health insurance or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the US Department of Health and Human Services. We will provide you with assistance in obtaining the address to file your complaint if needed.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the US Department of Health and Human Services.


Contact Officer: Laurie Kimble, Office Manager

phone: 860/724-4000

e-mail: orthotic@sbcglobal.net



(Please submit information only as you feel comfortable doing so)

Patientís Name___________________________________________________________________

Name of person completing survey________________________________________________

Telephone Number_______________________________ Age of patient___________________

Type of device worn______________________________________________________________


Location where you met with practitioner________________________________________________________

Name of practitioner____________________________________________________




                                                                                                                      POOR                  Excellent

1) My appointment was scheduled in a reasonable amount of time                  1    2    3    4    5

and the person with whom I spoke was courteous and helpful.


2) When you arrived for your appointment, for how long did you have to wait to be seen by the practitioner?__________________________


3) How well were the insurance co-pay and billing procedures explained to you?          1    2    3    4    5


What could we do to make this better? ______________________________________________________________________________



4) I found the waiting and treatment areas clean and well maintained.              1    2    3    4    5


5) The services provided to me were delivered in a reasonable           1    2    3    4    5

amount of time.


6) The appearance and workmanship of my orthosis/prosthesis is to my         1    2   3   4    5



7) The Orthotist/Prosthetist who provided my service was very         1    2    3    4    5

knowledgeable and skillful.


8) I received specific recommendations and/or instructions on         YES       NO

proper care and use of my orthosis/prosthesis.


9) After the practitioner left, I found the instructions and/or educational information provided to be useful to me.         1    2    3    4    5


                                                                                                            POOR                       EXCELLENT

10) Overall, I was satisfied with the quality treatment I received.             1    2    3    4    5

from ________________________________________________________.


11) What were your expectations for this device?




12) How well did what we provided reach that expectation?




13) What can you not do that you had hoped to be able to do?



14) If the purpose of the device was to alleviate pain, how well do you feel the device achieved that?         1   2   3   4   5




15) What is your level of Comfort today, compared to when you first arrived for service?




16) I would recommend Ability P & O to others requiring such services.         YES       NO


17) What needs to be improved?




I would like to speak to someone from Ability P & O about the services provided.       YES       NO

Phone Number: ________________________