2375 Wall St SE Ste 240, Conyers, GA 30013
Your Place for Pelvic Floor Occupational Therapy in Southeast Atlanta
                                       Call Us to speak to an OT! (770)740-5599

Functional Vitality Privacy Policy

Functional Vitality, LLC (“us,” “we,” or “our”) operates this website (the “Site”) and your privacy is important to us. This Privacy Policy is applicable to you upon your access and use of the Site, and informs you of our policies regarding the collection, use, protection, and disclosure of information we receive from users of the Site.

Please read the Privacy Policy carefully before you start to use the Site and note that this Privacy Policy is different from the Notice of Privacy Practices of Functional Vitality practices. Notice of Privacy Practices describe privacy practices and your privacy rights with respect to your “protected health information” (as that term is defined by the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, as amended and supplemented from time to time (“HIPAA”)).

How We Collect Personal Information

Personal Information is information that directly identifies you and includes, but is not limited to, your name, email address, mailing address, and phone number. For example, we may ask you to provide us with Personal Information that can be used to contact you when completing a form on the Site.

How We Use Your Personal Information

We may disclose Personal Information that we collect or you provide as described in this Privacy Policy:

  • To present our Site and its contents to you.
  • To provide you with information or services that you request from us, such as sending you certain informational materials.
  • To contractors, service providers, and other third parties we use to support our business and who are bound by contractual obligations to keep Personal Information confidential and use it only for the purposes for which we disclose it to them.
  • To fulfill the purpose for which you provide it.
  • To comply with any court order, law or legal process, including to respond to any government or regulatory request.
  • With your consent.

Collection and Use of Automatic Information

We may collect automatic, anonymous information such as browser type and version, browser language, your operating system and platform, and the Internet Protocol (IP) address used to connect your computer to the Internet. This information does not identify you, but is statistical data used for analytical purposes and helps us provide more relevant services to users. We may use this information to administer and troubleshoot issues directly related to the Site, such as Site administration or to analyze certain trends in Site usage. The technology we use to obtain this information includes the use of cookies. Cookies are small files placed on the hard drive of your computer to identify you when you visit a website. You may refuse to accept cookies by activating the appropriate setting on your browser. If you disable or refuse cookies, please note that some parts of this Site may then be inaccessible or not function properly. Unless you have adjusted your browser setting to refuse cookies, our system will issue cookies when you direct your browser to our Site.

Contact Us

If you have any questions about this Privacy Policy, please contact us at support@functionalvitalitymfr.com

Good Faith Estimate for Health Care Items and Services Notice

OMB Control Number [0938-XXXX] Expiration Date [MM/DD/YYYY

Disclaimers: The Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate costs are estimates and not the final overall total charges. The Good Faith Estimate is not a contract and does not require you [uninsured (or self- pay) individual] to obtain the items and services from any of the providers or facilities identified on the Good Faith Estimate. Additional items and/or services that are not in the Good Faith Estimate may be recommended by the convening provider as part of the course of care, that must be scheduled separately and are not reflected in the good faith estimate (such as rehabilitation therapies or other post treatment items or services) and information regarding how an you [uninsured (or self-pay) individual] can obtain a good faith estimate for such items or services.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know 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 to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. The patient-provider dispute resolution process may be started if the actual billed charges are $400 more than the expected charges included in the good faith estimate. 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 this 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 the Department of Health & Human Services (HHS) at 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 HHS at 1-877-696-6775.

 

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

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