Mailing Address
Please list below who may have access to the patient’s medical information and the relationship to the patient. All persons listed will be authorized to accompany patient at appointments and act as a medical decision maker on the patient’s behalf.
Add new row
Completed By:
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Thank you for choosing The Pediatric Center and/or Sabine Urgent Care as your medical home. We are dedicated to providing the best possible care for your family, and we want you to understand our policies.
Authorization for Treatment and Acknowledgement of Privacy Practices
Authorization and Acknowledgement of Insurance and Financial Policies
I have read and understand the practice’s Acknowledgements and Authorizations notice and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice periodically.
This Notice of Privacy Practice describes how we may use and disclose your protected health information (PHI) to coordinate treatment, payment, or healthcare operations and other purposes that are required by law. It also describes your rights to access and control your PHI. PHI includes information that may identify you and that relates to your past, present, or future physical or mental health and related health care services.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
PHI may be used and disclosed by our practice and other medical professionals that are involved in your care, to facilitate payment of services, and any other use required by law.
Treatment. We will use and disclose PHI to provide and coordinate medical care. This would include a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose and treat you.
Payment. PHI will be used to obtain payment for health care services. For example, obtaining approval for a hospital stay may require that relevant PHI be disclosed to the health plan to obtain approval for hospital admission.
Healthcare Operations. We may use or disclose PHI to support the business activities of THE PEDIATRIC CENTER AND/OR SABINE URGENT CARE. These activities include, but are not limited to, quality assessment activities, employee review activities, and training of medical provider students. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call patients by name in the waiting room at the time of service and use PHI to confirm appointments.
Other. We may use or disclose PHI in the following situations without your authorization to include: as required by law; Public Health issues; Communicable Disease; Health Oversight Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Criminal Activity; Military Activity and National Security; Workers’ Compensation; and Inmates Required Uses and Disclosures. Under the law, we must make disclosures as required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500
Other permitted and required uses and disclosures will be made only with your consent.
Patient Access to Medical Records. You have the right to review and copy your PHI. Under federal law, however, you may not review or copy the following records: psychotherapy notes, information completed in anticipation of a civil, criminal, or administrative action, and PHI that is subject to law that prohibits access to PHI. You have the right to receive an accounting of certain PHI disclosures made on your behalf.
You have the right to request a restriction of your protected health information. Your request must state the specific restriction requested and to whom you want the restriction to apply. Our office is not required to agree to a restriction that you may request. If your provider believes it is necessary to permit use and disclosure of your PHI, the restriction will not be granted.
You have the right to request to receive confidential communications from us by alternative means.
You have the right to request amendment of your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we will review your request further.
Patients have a right to:
i. Receive information about services and providers
ii. Be treated with respect in recognition of their dignity and right to privacy.
iii. Participate with providers in decision making regarding their health care inclusive to:
a. Attaining written consent to treat
b. Make the final determination in the course of action among clinically acceptable choices
c. Be represented by parents, guardians, family members, or other conservators when the patients are unable to fully participate in their treatment decisions with proper legal documentation
d. Acknowledgment of advanced directive.
iv. Discussion of appropriate or medically necessary treatment options for their conditions
v. Voice complaints or appeals about their care through the complaint process
vi. Be represented by parents, guardians, family members or other conservators when the members are unable to fully participate in their treatment decisions with proper legal documentation
vii. Discuss potential treatment options (without regard to plan coverage), side effects of treatment, and management of symptoms. Practitioners will educate patients regarding their health needs and share findings of history and physical examinations.
viii. Make the final determination regarding clinically acceptable choices.
ix. Have an Advance Directive acknowledged by the clinic.
Patients have the responsibility to:
i. Provide, to the extent possible, information that its providers need in order to care for them. If patient has an advanced directive, it is imperative that patients provide this information to the clinic for acknowledgement.
ii. Follow the plans and instructions for care that they have agreed on with their providers.
Complaints. You may submit a complaint if you believe your rights have been violated. Please contact our Practice Manager at (337) 239-2207. In the event your complaint remains unresolved with The Pediatric Center and/or Sabine Urgent Care, you may file a complaint with our accreditor, The Compliance Team, Inc. via their website (www.thecomplianceteam.org) or via phone at (888) 291-5353.
We are required to provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this document, please ask to speak with our Practice Manager. The Pediatric Center and/or Sabine Urgent Care reserve the right to change the terms of this notice.
Your signature below is only acknowledgement that you have received this Notice of our Privacy Practices and Patient Rights and Responsibilities.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use: