Privacy Policy



Sport-Ortho Urgent Care, P.C. makes, keeps, uses and discloses records containing your medical information. 

“Medical information” as those words are used in this Notice includes your billing, personal, demographic, financial (social security number, banking / credit / debit information), health/clinical treatment, and payment information and sensitive information[1] and any other information created/received by or included within our medical or other records about you.  As our patient, we will use and disclose your medical information –

  • To provide treatment to you and to keep medical records describing your care,
  • To receive payment for the care we provide,
  • To conduct our business activities relating to the services and facilities of the Practice, and
  • To comply with federal and state law.

This Notice summarizes the ways Sport-Ortho Urgent Care, P.C. and those people and companies covered by this Notice (as noted below) may use and disclose medical information about you.  It also describes your legal rights and our duties related to the use and disclosure of your medical information. 

When we use the word “we” or “us” or “the Practice,” we mean all the persons/entities covered by this Notice and listed below, its facilities, employees, medical professionals and other persons/companies not employed/owned by us who assist us with your treatment, payment or  activities of our business as a healthcare provider.


The following people and companies are covered by this Joint Notice:

  • All full-time, part-time, and leased employees, staff, and other personnel;
  • All entities, sites and locations under the management of Sport Ortho.These facilities and their staffs and outside vendors may share information with each other for your treatment, payment and business purposes described in this Notice;
  • Persons or entities performing services at or for Sport Ortho under business associate or other agreements to which disclosure of medical information is permitted by law;
  • Persons or entities with whom we participate in managed care arrangements;
  • Volunteers and medical, nursing and other health care students; and
  • Employed and outside, independent members of our Medical Staff (doctors who provide services at our facilities) and other medical and clinical professionals involved in your care or performing peer review, quality improvement, medical education and other services for Sport Ortho.


We use and disclose medical information in the ways described below.

Treatment.  We use and disclose your medical information to provide treatment or services to you.  We disclose medical information about you to doctors, nurses, technicians, therapists, medical, nursing or other health care students, and others taking care of you or providing consults about your care both inside and outside of our Practice.  We use and disclose your medical information to coordinate or manage your care.  We may send medical information to doctors or healthcare people/facilities/businesses who may be involved in your past or future care, including but not limited to, any primary care doctor, specialist, therapist, facility, laboratories, imaging centers, home health service, nursing home, hospice, pharmacy, or other doctor listed within your medical record or paperwork.   (For example,  we may send a copy of your record to your primary care or specialist  doctor so they can follow-up on your care.)  We share your medical information to schedule/coordinate tests, medications, and procedures you need – such as prescriptions, laboratory tests and x-rays.  We may release medical information in emergencies.

Payment.  We use and disclose your medical information so the treatment and services you receive can be billed and collected from you, an insurance company or other company or person.  As examples, we may give your insurance company (e.g., Medicare, Medicaid, CHAMPUS/TRICARE, or a private insurance company) information about a surgery you received so insurance will pay us for the surgery.  We also may tell your insurance company about a treatment you are going to receive in order to know whether you have insurance coverage for that treatment and to obtain prior approval from the insurance company to cover payment for the treatment.  We disclose your information to collection agencies to obtain overdue payment.  We might disclose information to a regulatory agency or other entity to determine whether the services we provided were good, medical necessary or appropriately billed. We may provide your information to ambulance companies so they can get paid for their services.

Health Care Operations.  We use and disclose your medical information for any business reason  to run our Practice and other facilities as a business and as a licensed/certified/accredited facility, including uses/disclosures of your information such as in the following examples: (1) Conducting quality or patient safety activities,  population-based activities relating to improving health or reducing health care costs, case management and care coordination, and contacting of healthcare providers and you with information about treatment alternatives; (2) Reviewing healthcare professionals’ backgrounds and grading their performance, conducting training programs for staff, students, trainees, or practitioners and non-healthcare professionals;  performing accreditation, licensing, or credentialing activities; (3) Engaging in activities related to health insurance benefits,  (4) Conducting or arranging for medical review, legal services, and auditing functions; (5) Business planning, development, and management activities, including things like customer service,  resolving complaints, sale or transfer of all or part of our entities and the background research related to such activities; and (6) Creating and using de-identified health information or a limited data set or having a business associate combine data or do other tasks for various operational purposes.

As examples, we may disclose your medical information to our Medical Staff to review the care provided to you.  We may disclose information to doctors, nurses, therapists, technicians, medical/nursing or other students, and personnel for teaching purposes.  We may combine medical information about many patients to decide what services we should offer and whether new services are cost-effective and to compare our quality with others.  We may remove your identifying information from your medical information so others may use it to study health care services and products.


We may release now or in the future your medical information  to local, regional, state or national health information exchanges and/or health information networks, including but not limited to local and regional HIEs that connect to other providers and other HIEs within the State and throughout the country).

All health information exchanges and networks that are provided medical information by us are referred collectively to as “HIEs” in this Notice.  HIEs provide healthcare providers inside our Practice and outside doctors, health facilities and their service providers, insurance companies, other payors, and others with the capability to share or “exchange” medical information about you electronically among each other. HIEs are designed to provide your treatment providers across the country with greater access to your medical history with the goal of enhancing communication between providers and providing patients with safer/better care. Healthcare providers who choose to participate in HIEs will have access to all your personal or medical information that has been uploaded into or that is accessible through the HIEs and may use or disclose that information for treatment, payment or healthcare operations, or as otherwise required/allowed by state and federal law. (For example, your primary care physician may have access to your oncologist’s summary of care documents and lab work through the HIEs, etc.)  The information in these HIEs is stored and backed-up by servers owned/leased by multiple outside companies in numerous locations. Do not assume your health care providers have access to any or all of your medical information. This Notice is to let you know we participate in HIEs. However, we may not actually upload your past, present, or future medical information into HIEs, and your other healthcare providers may not have access to those HIEs.  If in doubt, ask your doctor if he/she has your full medical record and always notify your healthcare provider of your full medical history prior to seeking services.

SENSITIVE INFORMATION: Sensitive information is patient information about things such as HIV/AIDs or other communicable diseases, mental health, or substance, drug, and alcohol treatment information, abortion information, pregnancy prevention, etc. There could be mental health or substance abuse, drug, or alcohol or other sensitive information  within other parts of your medical record that might be seen in the HIEs. Because sensitive information cannot be completely isolated from other medical information and because we do not have control of all HIE users, there is a chance that sensitive information could be included within your medical information and disclosed.  Therefore, if you are concerned at all about a certain piece of medical information being used / disclosed / redisclosed / known, we strongly recommend you opt-out of participation in the HIEs. When you opt out, your name and identification information will still appear in the HIE servers and directory list, but outside providers should not be able to actually access documents about you.



Patient Portal / Other Patient Electronic Correspondence.   We may use and disclose patient information through various, secure patient portals which allow you to view, download and transmit certain parts of your medical information (e.g., summary documents, lab results, billing information, etc.) and communicate with certain health care providers in a secure manner when using the portal.

Contact Information – Home and Email Addresses/Phone Numbers.    If you provide us with a home or email address or other contact information during any registration or administrative process, we will assume that the information you provided us is accurate and that you are consenting to our using this information  to communicate with you about various things related to your health care treatment  (e.g., patient portals, etc.),  payment for service  (invoices, etc.) and health care operations (e.g.,  patient surveys, breach notifications,  fundraising, etc.).    It is your sole responsibility to notify us of a change of this information.   We reserve the right to utilize third parties to update this information for our records on an as-needed basis.

Requests by you to email your medical information to an outside person or private email address (such as a Yahoo, Gmail, etc., account) or to post your information in drop boxes, on flash drives/CDs, etc. are  not secure. We are not responsible if this confidential information is redisclosed by an authorized recipient.  We are not responsible for subsequent damage, alteration or misuse of the data.    If you share an email account with another person (e.g.,   your spouse/partner/roommate) or choose to store, print, email, or post medical information, it may not be secure.

Health Services, Products, Treatment Alternatives and Health-Related Benefits.  We use and disclose your medical information in providing face-to-face communications; promotional gifts; refill reminders or communications about a drug or biologic; case management or care coordination, or to direct or recommend alternative treatments, therapies, providers, or settings of care; or to describe a health-related product/service (or payment for such product/service) that is provided through a benefit plan; or to offer information on other providers participating in a healthcare network, or to offer other health-related products, benefits or services.   We use and disclose your medical information to contact and remind you of appointments.  

Fundraising.  We use and disclose your medical information to raise money.  You have a right to opt-out of receiving fundraising requests.  If you do not want us to contact you for fundraising purposes, please notify the Registration Clerk or our Privacy Officer. 

Individuals Involved in Your Care or Payment for Your Care.  We are allowed to release your medical information to the person you named in your Durable Power of Attorney for Health Care (if you have one), or otherwise to a friend or family member who is your personal representative (i.e., empowered under state or other law to make health-related decisions for you).  We give medical information to those who help pay for your care.  We may disclose your medical information to an entity assisting in disaster relief efforts so that your family can be notified about your condition.  We are allowed by law to speak with those who are/were involved in your care/payment activities while being treated as patient and/or even after your death, if we reasonably infer based on our professional judgment that you would not object.  If you do not wish for us to speak with a particular person about your care, you should notify the Registration Clerk, your nurse,  or care provider.  

Research.  We may use and disclose your medical information for research purposes.  Most research projects are subject to a special approval process. The law allows some research to be done using your medical information without requiring your written approval.

Required By Law.  We will disclose your medical information when the law requires it.  For example, the Practice and its personnel must comply with child and elder abuse reporting laws and laws requiring us to report certain diseases or injuries or deaths to state or federal agencies.

Serious Threat to Health or Safety.  We may use and disclose your medical information if necessary to prevent a serious threat to health/safety of you, the public or another person.

Organ and Tissue Donation.  If you are an organ or blood donor, we may release your medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation or blood bank.

Military and Veterans.  If you are a member of the U.S. or foreign armed forces, we will release your medical information as required by military command authorities.

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.

Minors.  If you are under 18 years old, we release certain types of your medical information to your parent(s) or guardian if such release is required or permitted by law.  

Public Health Risks.  We disclose your medical information (and certain test results) for public health purposes, such as –

  • To a public health authority to prevent or control communicable diseases (including sexually transmitted diseases), injury or disability,
  • To report births and deaths,
  • To report child, elder or adult abuse, neglect or domestic violence,
  • To report to FDA or other authority reactions to medications or problems with products,
  • 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 getting or spreading a disease or condition,
  • To notify employer of work-related illness or injury (in certain cases),  and
  • To a school to disclose whether immunizations have been obtained.

Health Oversight Activities.  We disclose your medical information to a federal or state agencies for health oversight activities such as audits, investigations, inspections, and licensure of the Practice and of the providers who treated you.  These activities are necessary for the government  and others to monitor the health care system, government programs, and compliance with laws.

Lawsuits and Disputes.  We may disclose your medical information to respond to a court or governmental agency request, order or a search warrant.  We also may disclose your medical information in response to a subpoena, discovery request, or other lawful process.

Law Enforcement.  We disclose your medical information for a law enforcement purpose  to report suspicion of death/injury resulting from criminal conduct or a crime on our premises, in emergencies, and as otherwise allowed or required by law. 

Medical Examiners and Funeral Directors.  We disclose medical information to the coroner or medical examiner, and funeral director so they may carry out their duties.

National Security.  We may disclose your medical information to authorized federal officials for national security activities authorized by law.

Protective Services.  We may disclose your medical information to authorized federal officials so they may provide protection to the President of the United States and other persons.

Inmates.  If you are an inmate of a correctional institution or under the custody of a law enforcement officer, we release medical information to the correctional institution or a law enforcement officer.  This release would be necessary for us to provide you with healthcare, to protect your health and safety or the health and safety of others, or for the safety and security of the law enforcement officer or the correctional institution.

Incidental Disclosures.   Medical information may be overheard by people who not directly involved in your care.  For example, visitors could overhear a conversation about you or see you getting treatment.  

Business Associates.  Your medical information will be disclosed to people or companies outside our Practice who provide services to us. 

Sensitive MEDICAL Information.

State law provides special protection for certain types of medical information, including information about substance, alcohol or drug abuse, mental health, abortion, pregnancy prevention, and AIDS/HIV or other communicable diseases, and may limit how we may disclose information about you to others.  We obtain your consent during registration to disclose sensitive information to provide you care and to get paid for our services.

  • Confidentiality of  Substance Use Disorder Patient Records and Information

The confidentiality of substance use disorder patient records maintained by a federally assisted alcohol and drug rehabilitation program is protected by Federal law. Generally, such Programs may not disclose to a person outside of the Program where a patient is getting services, or disclose any information identifying a patient as an alcohol or drug user,  unless:

(1) The patient consents;

(2) The disclosure is allowed by a court order;

(3) The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation;

(4)  A crime is committed on the promises or against personnel who work for the program; or

(4) Unless otherwise allowed by the law.

This law does not protect any program information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.  Violation of the federal confidentiality law by a federally assisted alcohol and drug rehabilitation program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations by contacting Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD  20857.  For more information, see 42 U.S.C. § 290dd-3 – § 290ee-3 and 42 C.F.R. Part 2 for federal laws related to Substance Abuse Disorder Records.


Right to Review and Right to Request a Copy.  You have the right to review and get a copy of  your complete laboratory reports, medical and billing records that are held by us in a designated record set (including the right to obtain an electronic copy if readily producible by us in the form and format requested).  The Contact Person listed below can help you with this request. We have a form you can fill out to request to review or get a copy of your records, and can tell you how much your copies will cost. We are allowed by law to charge a reasonable cost-based fee for labor, supplies, postage and the time to prepare any summary.  We will tell you if it cannot fulfill your request.  If you are denied the right to see or copy your information, you may ask us to reconsider our decision.  There may be times that your doctor in professional judgment may think it is not in your best interest to have access to your medical record.     Depending on the reason for denial of a request, we may ask a licensed health care professional to review your request and reconsider.

Right to Amend.  If you feel your medical information in our records is incorrect or incomplete, you may ask us in writing to amend the information.  You must provide a reason to support your requested amendment.  We will tell you if we cannot fulfill your request.  The Contact Person listed below can help you with your request.

Right to an Accounting of Disclosures.  You have the right to make a written request for a list of certain disclosures we have made of your medical information within a certain period of time.  This list is not required to include all disclosures we make.  For example, disclosure for treatment, payment, administrative purposes,  disclosures made to you or that you authorized are not required to be listed.  The Contact Person listed below can help you with this request.

Right to Request Restrictions on Disclosures.  You have the right to make a written request to limit the medical information we use or disclose about you for treatment, payment or health care operations.  You also have the right to request a limit on your medical information that we disclose to someone involved in your care or the payment for your care, like a family member or friend.  We are generally not required to agree to your request, except as follows:

  • Payor Exception:  If otherwise allowed by law, we are required to agree to a requested restriction, if (1) the disclosure is to your health insurance plan for purposes of carrying out payment or health care operations and (2) the medical information to be restricted relates solely to a health care item or service for which all parties have been paid in full out of pocket.    NOTE:   During a single Practice visit, you may receive a bill for payment from multiple sources, including the hospital, laboratories, individual physicians who cared for you, specialists, radiologists, etc.   Therefore, if you wish to fully restrict disclosure to your health insurance company, you must contact each independent health care provider separately and submit payment in full to each individual provider. We expressly disclaims any responsibility for independent medical staff acts or omissions relating to your HIPAA privacy rights.

If we agree to a request for restriction, then we will comply with your request unless the information is needed to provide you with emergency treatment or to make a disclosure that is required under law.  In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your adult children.  The Contact Person listed below can help you with these requests if needed.

Right to Request Confidential Communications.  You have the right to make a written request that we communicate with you about medical matters in a certain way or at a certain location.  For example, you can ask that we contact you only at work or by mail.  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.  The Contact Person listed below can help you with these requests if needed.

Right to a Paper Copy of This Notice.  You have the right to receive a paper copy of this Notice at any time,  even if you have agreed to receive this Notice electronically.  You may obtain a copy of this Notice at our website or a paper copy from the Contact Person listed below.

Right to Receive a Notice of a Breach of Unsecured Medical / Billing Information.     You have the right to receive a notice in writing of a breach of your unsecured medical or billing or financial information.   Your physicians or other independent entities involved in your care will be solely responsible for notifying you of any breaches that result from their actions / inactions. 


We reserve the right to change this Notice.  We reserve the right to make the revised or changed Notice effective for medical information we already have and have used and disclosed about you, as well as for any information we receive in the future.  We will post the current Notice at registration site within the Practice and on our website, in order to alert you to changes. 


If you believe your privacy rights have been violated, you may file a written complaint with Sport Ortho  or with the Secretary of the Department of Health and Human Services or HHS.  To file a complaint with us, please contact Sport Ortho, .    Generally, a complaint must be filed with HHS within 180 days after the act / omission occurred, or within 180 days of when you knew or should have known of the act / omission.  You will not be denied care or discriminated against by us for filing a complaint.



      Uses and disclosures of your medical information that are not covered generally by this Notice or that are not allowed or required by law or by our policies or procedures will be made with your written permission.  If you sign an authorization form for a special use/disclosure of information, then you can revoke that authorization, in writing, at any time by contacting our Privacy Officer and filling out requested  forms.  But, we will not be able to take back any uses/disclosures already made with your past permission, and we must comply with the laws that require certain uses and disclosures of patient information. We are not allowed to delete medical or billing records that are subject to retention laws and are in the custody of other providers.

If you have any questions about this Notice, please contact our Privacy Officer at  Sport Ortho Urgent Care Attn: Privacy Officer / COO at 5000 Crossings Circle, Mount Juliet, TN  37122 or call and ask to speak to our COO at (615) 553-5000.

Revised January 2018; March 2018 

Patient HIPAA Form