Overtime Sports Clinic
Effective Date: August 15, 2026

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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, HOW YOU CAN ACCESS THIS INFORMATION, AND YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION. PLEASE REVIEW IT CAREFULLY.

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Your Rights

You have certain rights regarding your health information. You may:

• Get a copy of your medical record. You may request an electronic or paper copy of your medical record and other health information we maintain about you.

• Ask us to correct your medical record. If you believe information is incorrect or incomplete, you may request that we correct it.

• Request confidential communication. You may ask us to contact you in a specific way or at a specific location.

• Ask us to limit what we use or share. You may request restrictions on certain uses or disclosures of your health information. We are not required to agree to every request unless otherwise required by law.

• Get a list of certain disclosures. You may request an accounting of certain disclosures of your health information for the six years prior to your request.

• Get a copy of this Notice. You may request a paper or electronic copy of this Notice at any time.

• Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian or authorized personal representative, that person may exercise your rights as permitted by law.

• File a complaint. You may file a complaint if you believe your privacy rights have been violated. We will not retaliate against you for filing a complaint.

If you pay for a healthcare service out-of-pocket in full, you may ask us not to share information about that service with your health insurer for payment or healthcare operations. We will honor that request unless disclosure is required by law.

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Your Choices

For certain health information, you may tell us your preferences about what we share.

These situations may include:

• Sharing information with family members, caregivers, or others involved in your care

• Sharing information during a disaster-relief situation

• Certain marketing or promotional activities

• Other uses or disclosures for which your authorization is required

If you are unable to communicate your preference, we may share information when legally permitted if we believe it is in your best interest.

We will obtain your written authorization when required by law before using your protected health information for marketing purposes or selling your protected health information.

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How We May Use and Share Your Information

We may use or disclose your health information without additional written authorization when permitted or required by law.

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Treatment

We may use your health information and share relevant information with other healthcare professionals involved in your care.

Example: We may communicate with a physician or other healthcare professional regarding your injury, treatment, or rehabilitation when permitted by law.

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Healthcare Operations

We may use and share your health information to operate our practice, coordinate services, improve quality of care, and conduct necessary administrative activities.

Example: We may use health information to manage your treatment, maintain records, or evaluate the quality of our services.

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Payment

We may use and disclose your health information as necessary for billing, payment, reimbursement, or other payment-related activities.

Example: At your request or when otherwise permitted, information may be used to prepare documentation related to reimbursement for services.

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Other Uses and Disclosures

We may also use or disclose your health information when permitted or required for purposes such as:

• Public health and safety activities

• Reporting suspected abuse, neglect, or domestic violence as required by law

• Health oversight activities

• Compliance with federal or state law

• Workers' compensation matters

• Law enforcement or other government requests

• Responding to lawsuits, court orders, subpoenas, or other legal proceedings

• Working with coroners, medical examiners, or funeral directors

• Organ and tissue donation

• Certain research activities permitted by law

• Preventing or reducing a serious threat to health or safety

Other uses or disclosures not described in this Notice will generally require your written authorization. If you provide authorization, you may revoke it in writing at any time, except to the extent that we have already acted based on your authorization.

Substance Use Disorder Records

Certain substance use disorder treatment records may receive additional protections under federal law.

To the extent Overtime Sports Clinic maintains records subject to 42 CFR Part 2, those records will receive the additional protections required by applicable law, including restrictions on their use or disclosure in certain investigations or legal proceedings without appropriate written consent or legal authorization.

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Our Responsibilities

Overtime Sports Clinic is required by law to:

• Maintain the privacy and security of your protected health information.

• Provide you with this Notice explaining our legal duties and privacy practices.

• Follow the duties and privacy practices described in the Notice currently in effect.

• Notify you promptly if a breach occurs that may have compromised the privacy or security of your information, when notification is required by law.

• Obtain your written authorization before using or sharing your information when authorization is required by law.

We will not use or disclose your health information other than as described in this Notice unless you authorize us to do so in writing or the use or disclosure is otherwise permitted or required by law.

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Changes to This Notice

We may change the terms of this Notice and our privacy practices. Changes may apply to health information we already maintain as well as information we receive in the future.

The current Notice will be available through Overtime Sports Clinic, at our office, and on our website.

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Questions, Requests, or Complaints

If you have questions about this Notice, want to exercise one of your privacy rights, or believe your privacy rights have been violated, please contact:

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Dr. Bryce Campbell, DPT
Privacy Officer
Overtime Sports Clinic
Email: bryce@campbelldpt.com
Phone: 317-572-7717

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You may also file a complaint with the:

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U.S. Department of Health and Human Services
Office for Civil Rights

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Information about filing a HIPAA complaint is available through the U.S. Department of Health and Human Services.

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Overtime Sports Clinic will not retaliate against you for filing a complaint or exercising your privacy rights.

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Effective Date: August 15, 2026