NOTICE OF PRIVACY PRACTICES
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) ACKNOWLEDGEMENT
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, legal obligations, and your rights concerning your health information (“Protected Health Information” or “PHI”). We must follow the privacy practices that are described in this Notice (which may be amended from time to time). For more information about our privacy practices, or for additional copies of this Notice,
I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION:
A. Your PHI may be used and disclosed by the physician, our office staff and others outside of our offices that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the business, and any other use required by law. We may use and disclose PHI without your written authorization for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law.
1. Treatment: We may use and disclose PHI in order to provide treatment to you. For example, we may use PHI including your medication history to diagnose, treat, and provide medical services to you. In addition, we may disclose PHI to other health care providers involved in your treatment.
2. Payment: Under federal law we may use or disclose PHI so that services you receive are appropriately billed to, and payment is collected from, your health plan. By way of example, we may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services. We may contact the Guarantor for your visit in order to obtain payment.
3. Health Care Operations: We may use or disclose your PHI in order to support our business activities. These activities include, but are not limited to business associates, quality assessment activities, internal investigations, performance reviews, and training employees. In addition, we will use a sign-in sheet at the registration desk where you will be asked to provide your name and date of birth. We may also call you by name in the waiting room when the physician is ready to see you. We may use or disclose your PHI to contact you to remind you of an appointment, to notify you of test results, to inform you of health- related services that may be of interest to you, and to check on your treatment, progress, and satisfaction with our services.
4. Required or Permitted by Law: As required by Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donation, Research, Criminal Activity, Military Activity, National Security, Worker’s Compensation, Inmates, and other Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services.
B. Permissible Uses and Disclosures That May Be Made Without Your Authorization, But For Which You Have An Opportunity to Object.
1. Family and Other Persons Involved in Your Care. We may use or disclose 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 disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
2. Disaster Relief Efforts. We may use or disclose protected health information to a public or private entity authorized by law or its charter to assist in disaster relief efforts for the purpose of coordinating notification of family members of your location, general condition, or death.
C. Other permitted and required uses and disclosures: Use or Disclose of your PHI for marketing or sale of your PHI to third parties, will be made only with your authorization. Once given, you may withdraw authorization at any time in writing.
II. YOUR INDIVIDUAL RIGHTS
A. Right to Inspect and Copy. You may request access to your medical records and billing records maintained by us in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, we may deny access to your records. Under federal law, you may not inspect or copy psychotherapy notes, information compiled in anticipation of, or use in, a legal proceeding, and PHI that is otherwise prohibited. We may charge a fee for the costs of copying and sending you any records requested.
B. Right to Alternative Communications. You may request, and we will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.
C. Right to Request Restrictions. You may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or health care operations. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply. If you have paid for your services in full and ask us not to disclose your visit to your insurance company, we will honor that request. We are not required to agree to any other restriction that you may request.
D. Right to Accounting of Disclosures. Upon written request, you may obtain an accounting of certain disclosures of PHI made by us in the last six years. This right applies to disclosures for purposes other than treatment, payment or health care operations, excludes disclosures made to you or disclosures otherwise authorized by you, and is subject to other restrictions and limitations. We are required by law to notify you if your unsecured PHI is breached.
E. Right to Request Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If we deny your written request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
F. Right to Obtain Notice. You have the right to obtain a paper copy of this Notice by submitting a request to the center’s Compliance Officer at any time.
G. Questions and Complaints. If you desire further information about your privacy rights, or are concerned that we have violated your privacy rights, you may contact the center’s Compliance Officer. You may also file a written complaint with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. We will not retaliate against you if you file a complaint with the Director or with our office.
III. EFFECTIVE DATE AND CHANGES TO THIS NOTICE
A. Effective Date. This Notice is effective on February 3, 2015.
B. Changes to this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the revised notice in the waiting area of our office and on our web site. You may also obtain any revised notice by contacting the center’s Compliance Officer. I have reviewed this Notice of Privacy Practices and understand that I may request a copy of the policy at any time.
Health Insurance Portability and Accountability Act (HIPAA) Acknowledge By acknowledging below, you consent to our use and disclosure of your medical information so that Swiftcare Urgent Care may treat you, seek payment from third parties for such treatment, and generally carry on Swiftcare Urgent Care’s health care operations. You also consent to Swiftcare Urgent Care’s disclosure of your medical information to insurers and providers outside of Swiftcare Urgent Care when necessary so that these insurers and/or providers may treat you, seek payment for that treatment, and for the purpose of their health care operations. You may refuse all or part of this consent. If you refuse use of your medical information for payment from your insurance company, you will be responsible for payment of your bills. This consent will be valid for the entire duration of treatment by Swiftcare Urgent Care unless you request the consent to be revoked
Consent for Treatment
I consent to the care and treatment by the attending physician, his/her associates or assistants. I acknowledge that no guarantees have been made as to the effect of such treatment.
Consent for Medication History
I consent to the attending physician, his/her associates or assistants to download the most recent medication history that is available from Pharmacy benefit Managers (PBM). I understand that this is to increase the quality of care and improve patient safety.
I authorize the release of any medical information necessary to determine liability for payment and to obtain reimbursement on any claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for all medical and/or surgical benefits, to include major medical benefits to which I am entitled including Medicare, private insurance and other agency reimbursements to Swiftcare Urgent Care. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original.
I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure the payment.
By signing below, I am confirming that I understand and consent to the Policies previously shown.