EmpoweredDecisions!™ Virtual Physical Therapy Program Participating Provider Notice of Privacy Practices



This notice is effective when you start treatment with a participating provider as part of the EmpoweredDecisons! Virtual Physical Therapy program (www.empowered-decisions.com).


This notice was first implemented on July 1, 2022.


This notice applies to the virtual physical therapy services provided to you by participating providers through the EmpoweredDecisions! Virtual Therapy program. The program is made available to you through your health plan sponsor. However, this notice covers the professional services you receive from the participating provider for virtual physical therapy. Your participating provider is a Covered Entity under HIPAA and required to provide you with this notice. Your provider will share information with the EmpoweredDecisions! program to process benefits available to you through your participating health plan.


Participating providers in the EmpoweredDecisions! Physical Therapy Program may have their own privacy official and may respond to your requests directly. In addition, the Privacy Office for EmpoweredDecisions! may help you reach your participating provider to exercise your privacy rights. You may contact your provider via the email used for your treatment under the program. You may reach the EmpoweredDecisions! Privacy Office by phone at (877) 427-4766 or by email at HIPAA@ashn.com.


Your Information. Your Rights. Participating Provider Responsibilities.
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.

Your Rights
You have the right to:
  • Get a copy of your paper or electronic medical record
  • Correct your paper or electronic medical record
  • Request confidential communication
  • Ask your participating provider to limit the information they share
  • Get a list of those with whom your participating provider shared your information
  • Get a copy of this privacy notice
  • Choose someone to act for you
  • File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that your participating provider uses and shares information as they:
  • Tell family and friends about your condition
  • Provide disaster relief
  • Include you in a hospital directory (please note that hospital directories are not applicable to the services provided)
  • Provide mental health care (please note that services available do not include mental health care)
  • Market participating provider services and sell your information (please note that participating providers will not sell your information or use it for marketing)
  • Raise funds (please note that participating provider will not use your information for fundraising)
Participating Provider Uses and Disclosures
Your participating provider may use and share your information as they:
  • Treat you
  • Run their organization
  • Bill for your services
  • Help with public health and safety issues
  • Do research
  • Comply with the law
  • Respond to organ and tissue donation requests
  • Work with a medical examiner or funeral director
  • Address workers’ compensation, law enforcement, and other government requests
  • Respond to lawsuits and legal actions
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of the participating provider responsibilities to help you.

Get an electronic or paper copy of your medical record
  • You can ask to see or get an electronic or paper copy of your medical record and other health information your participating provider has about you. Ask them how to do this.
  • Your participating provider will provide a copy or a summary of your health information, usually within 30 days of your request. They may charge a reasonable, cost-based fee.
Ask to correct your medical record
  • You can ask your participating provider to correct health information about you that you think is incorrect or incomplete. Ask them how to do this.
  • Your participating provider may say “no” to your request, but they’ll tell you why in writing within 60 days.
Request confidential communications
  • You can ask your participating provider to contact you in a specific way (for example, home or office phone), send mail or email to a different address.
  • They will say “yes” to all reasonable requests.
Ask to limit what your participating provider uses or shares
  • You can ask them not to use or share certain health information for treatment, payment, or their operations. They are not required to agree to your request, and they may say “no” if it would affect your care.
  • If you pay for a service or health care item out-of-pocket in full, you can ask them not to share that information for the purpose of payment or our operations with your health insurer. They will say “yes” unless a law requires them to share that information. Please note that the services available under the EmpoweredDecisions! Virtual Therapy program are not intended to be paid in full by you. Rather these services are expressly intended to be used by you for benefits under your participating health plan’s coverage available to you.
  • Participating provider will never share any substance abuse, reproductive health, STD and/or HIV-related treatment records without your written permission. Please note that services available under the program will not include such sensitive treatments.
Get a list of those with whom your participating provider has shared information
  • You can ask your participating provider for a list (accounting) of the times they’ve shared your health information for six years prior to the date you ask, who they shared it with, and why.
  • Your participating provider will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked them to make). They’ll provide one accounting a year for free but may charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask your participating provider for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. Your participating provider will provide you with a paper copy promptly.

Choose someone to act for you
  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • Your participating provider will make sure the person has this authority and can act for you before they take any action.
File a complaint if you feel your rights are violated
  • You can complain if you feel we have violated your rights by contacting us using the information on page 1.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights in writing to Centralized Case Management Operations, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201. Or you can visit www.hhs.gov/hipaa and select the Filing a Complaint option on the page.
  • You will not be retaliated against for filing a complaint.
Your Choices
For certain health information, you can tell your participating provider your choices about what they share. If you have a clear preference for how they share your information in the situations described below, talk to them. Tell them what you want them to do, and they will follow your instructions.

In these cases, you have both the right and choice to tell them to:
  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation
  • Include your information in a hospital directory (please note that hospital directories are not applicable to the program services.)
If you are not able to tell them your preference, for example if you are unconscious, they may go ahead and share your information if they believe it is in your best interest. They may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases they never share your information unless you give them written permission:
  • Marketing purposes (please note they will not use your information for marketing purposes)
  • Sale of your information (please note they will not sell your information)
  • Most sharing of psychotherapy notes (please note they do not create or maintain psychotherapy notes related to the program services)
In the case of fundraising:
  • They may contact you for fundraising efforts, but you can tell them not to contact you again. Please note they do not use your information for fundraising purposes under this program.

Participating Provider Uses and Disclosures
How do participating providers typically use or share your health information?
They typically use or share your health information in the following ways.
Treat you
They can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run their organization
They can use and share your health information to run their practice, improve your care, and contact you when necessary.
Example: They may use health information about you to manage your treatment and services.

Bill for your services
They can use and share your health information to bill and get payment from health plans or other entities.

Example: For services under this program, they will share your health information with American Specialty Health Group Management, Inc., American Specialty Health Group, Inc. and their affiliates that support the EmpoweredDecisions! Virtual Therapy program. This will also include your health care insurance or benefit plan participating in the program.

How else can your participating provider use or share your health information?
They are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. They have to meet many conditions in the law before they can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues

They can share health information about you for certain situations such as:
  • Preventing disease
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or safety

Do research
They can use or share your information for health research.

Comply with the law
They will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that they’re complying with federal privacy law.

Respond to organ and tissue donation requests
They can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director
They can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests
They can use or share health information about you:
  • For workers’ compensation claims
  • For law enforcement purposes or with a law enforcement official
  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions
They can share health information about you in response to a court or administrative order, or in response to a subpoena.

Their Responsibilities
  • They are required by law to maintain the privacy and security of your protected health information.
  • They will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • They must follow the duties and privacy practices described in this notice and give you a copy of it.
  • They will not use or share your information other than as described here unless you tell them they can in writing. If you tell them they can, you may change your mind at any time. Let them know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice
The terms of this notice can change, and the changes will apply to all information your participating provider has about you. The new notice will be available upon request. It may also be found on the EmpoweredDecisions! web site.






EmpoweredDecisions! is a registered trademark of American Specialty Health Incorporated and used with permission herein.