HIPAA Consent Form

Purpose

This notice describes how medical information about you may be used, disclosed, and how you can get access to this information. Please review this document carefully.

Patient Health Information (PHI) Under federal law, your patient health information (PHI) is protected and confidential. Patient health information (PHI) includes information about your symptoms, test results, diagnosis, treatment, and related medical information.

Your patient health information (PHI) also includes payment, billing and insurance information. We are committed to protect the privacy of your PHI.

How we use your patient health information (PHI)

This Notice of Privacy Practices (Notice) describes how we may use within our practice or network and disclose (share outside of our practice or network) your PHI to carry out treatment, payment or health care operations, for administrative purposes, for evaluation of the quality of care, and so forth.

We may also share your PHI for other purposes that are permitted or required by law.

This Notice also describes your rights to access and control your PHI.

Under some circumstances we may be required to use or disclose your PHI without your consent.

Treatment: We will use and disclose your PHI to provide you with medical treatment or services. We may also disclose your PHI to other health care providers who are participating in your treatment, to pharmacists who are filling your prescriptions, to laboratories performing tests, and to family members who are helping with your care, and so forth.

Payment: We will use and disclose your PHI for payment purposes. For example, we may need to obtain authorization from your insurance company before providing certain types of treatment. We will submit bills and maintain records of payments from your health plan.

PHI may be shared with the following: billing companies, insurance companies (health plans), government agencies in order to assist with qualifications of benefits, or collection agencies.

Operation: We may ask you to complete a sign-in sheet or staff members may ask you the reason for your visit so we can better care for you. Despite safeguards, it is always possible in a doctor’s office that you may learn information regarding other patients, or they may inadvertently learn something about you. In all cases, we expect and request that our patients maintain strict confidentiality of PHI.

We may use and disclose your PHI to perform various routine functions (e.g. quality evaluations or records analysis, training students, other health care providers or ancillary staff such as billing personnel, to assist in resolving problems or complaints within the practice).

We may use your PHI to contact you to provide information about referrals, for follow-up with lab results, to inquire about your health or for other reasons.

We may share your PHI with Business Associates who assist us in performing routine operational functions, but we will always obtain assurances from them to protect your PHI the same as we do.

Special Situations that DO NOT require your permission: We may be required by law to report gunshot wounds, suspected abuse or neglect, and so on; we may be required to disclose vital statistics, diseases, and similar information to public health authorities; we may be required to disclose information for audits and similar activities, in response to a subpoena or court order, or as required by law enforcement officials.

We may release information about you for worker’s compensation or similar programs to protect your health or the health of others or for legitimate government needs, for approved medical research, or to certain entities in the case of death.

Your PHI may also be shared if you are an inmate or under custody of the law which is necessary for your health or the health and safety of other individuals.

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel for activities deemed necessary by appropriate military command authorities, for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or to foreign military authority if you are a member of that foreign military services.

In some situations, we may ask for your written authorization before using or disclosing any identifiable health information about you. If you sign an authorization, you can later revoke the authorization.

Individual Rights

You have certain rights with regard to your PHI, for example: Unless you object, we may share your PHI with friends or family members, or other persons directly identified by you at the level they are involved in your care or payment of services. If you are not present or able to agree/object, the healthcare provider using professional judgment will determine if it is in your best interest to share the information.

We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.

We may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts.

You may request restrictions on certain uses and disclosures of your PHI.

We are not required to accept all restrictions. If you pay in full for a treatment or service immediately, you can request that we not share this information with your medical insurance provider or our Business Associates.

We will make every attempt to accommodate this request and, if we cannot, we will tell you prior to the treatment.

You may ask us to communicate with you confidentially by, for example, sending notices to a special address. In most cases, you have the right to get a copy of your PHI. There will be a charge for the copies.

If you believe information in your record is incorrect, or if important information is missing, you have the right to request that we amend the existing information by submitting a written request.

You may request a list of instances where we have disclosed PHI about you for reasons other than treatment, payment, or operations.

The first request in a 12 month period is free. There will be charges for additional reports. You have the right to obtain a paper copy of this Notice from us, upon request. We will provide you a copy of this Notice on the first day we treat you at our facility.

In an emergency situation we will give you this Notice as soon as possible.

You have the right to receive notification of any breach of your protected health information.

Health Information Exchange / CommonWell Health Information Exchange (HIE) / CommonWell is the electronic sharing of health information between participating providers in a way that ensures the secure exchange of health information to provide care to patients.

You have a right to opt-out of HIE / CommonWell participation. If you choose to opt-out, providers will not be able to search for your most recent health information when determining treatment.

Opting out will not affect your ability to access medical care.

If you do not wish to participate in the HIE / CommonWell, you may request a copy of our HIE / CommonWell Patient Opt-Out form by emailing: secure@elgreathealth.com

Our Legal Duty

We are required by law to protect and maintain the privacy of your PHI, to provide this Notice about our legal duties and privacy practices regarding PHI, and to abide by the terms of the Notice currently in effect.

We may update or change our privacy practices and policies at any time.

Before we make a significant change in our policies, we will change our Notice and post the new Notice in the admissions area and on our website at www.elgreathealthcareservices.com.

You can also request a copy of our Notice at any time.

If you are concerned about your privacy rights, or if you disagree with a decision we made about your records, you may contact the Privacy Officer listed below.

You may also send a written complaint to the U.S. Department of Health and Human Services.

You will not be penalized in any way for filing a complaint.

Contact Person If you have any questions, requests, or complaints, please contact our privacy officer at Elgreat Healthcare Center, 2301 Hilliard Road, Henrico VA 23228, Telephone 8045289752, or send an email to secure@elgreathealth.com

Consent to Treatment and Permission to Discuss PHI

Permission to Discuss PHI: I authorize Elgreat Healthcare Center and its agents to release my protected health information to the following individuals:

Consent to Treatment: I understand that as part of my healthcare, Elgreat Healthcare Center originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care and treatment. I also understand this information serves as:

• A basis for planning my care and treatment
• A means of communication among the many health professionals who contribute to my care
• A source of information for applying my diagnosis and surgical information to my bill
• A means by which a third-party payer can verify that services billed were actually provided
• And a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand Elgreat Healthcare Center reserves the right to change their notice and practices, a current version of which is available on the Elgreat Healthcare Center Web site (http://www.elgreathealthcareservices.com). I also understand that I have the right to restrict how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that Elgreat Healthcare Center is not required to agree to the restrictions requested. I have the right to request to receive confidential communications of protected health information by alternative means or at alternative locations. Such request must be in writing and Elgreat Healthcare Center will accommodate any reasonable requests.

By providing a cell number, I agree that Elgreat Healthcare Center, its affiliates, or those acting on their behalf, may call or text using an automatic telephone dialing system and/or a prerecorded message. With this consent, Elgreat Healthcare Center may call my home, cellular telephone, or other designated location and leave a message on voice mail or in person in reference to any items that assist Elgreat Healthcare Center in carrying out treatment, payment, and operations activities, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results.

With this consent, Elgreat Healthcare Center may mail to my home or other designated location any items that assist Elgreat Healthcare Center in carrying out treatment, payment, and operations activities, such as appointment reminders and other correspondence as long as they are marked Personal and Confidential.

With this consent, Elgreat Healthcare Center may e-mail or text me appointment reminders and patient statements.

By signing this form, I am consenting to Elgreat Healthcare Center’s use and disclose my PHI to carry out my treatment, payment, and operations activities. I may revoke my consent in writing except to the extent that Elgreat Healthcare Center has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Elgreat Healthcare Center may decline to provide treatment to me.

Insurance Authorization: I authorize the release of any medical information to any insurance company, Medigap Insurance, third party administrator, or other payer that is necessary to process the claim and request payment of benefits either to myself or to Elgreat Healthcare Center. I authorize Elgreat Healthcare Center and its agents to release medical information contained in my medical record to any insurance companies, federal programs or state programs with which I am insured or who are responsible for payment of my claim. If applicable, I certify that the information given by me in applying for payment under Title XVIII or XIX of the Social Security Act is correct. I request that payment of authorized benefits be made on my behalf for any services furnished to me by or in Elgreat Healthcare Center including physician services.

Financial Responsibility: I understand that I am financially responsible for all charges, whether or not covered by insurance. If I have an outstanding balance for more than ninety (90) days, Elgreat Healthcare Center will charge me a late payment fee of $20.00 and may refer my account to an outside collection agency or attorney. If I am referred to an outside collection agency for collections, I agree to pay a collection fee of 35% of the balance owed, or whatever amount is permitted by applicable state law, in addition to the balance owed. If I am referred to an attorney for collections, I agree to pay all attorneys’ fees and related costs, including court costs, in addition to the balance owed. In addition, if I have unpaid delinquent accounts, Elgreat Healthcare Center may discharge me as a patient and/or I may not be allowed to schedule any additional services unless special payment arrangements have been made.

Assignment of Benefits: In consideration for healthcare and subsequent services provided to me by Elgreat Healthcare Center, I hereby assign to Elgreat Healthcare Center and any holder of medical or other information about me, and their agents, any and all rights, benefits, and claims I may have under any policy of insurance and the proceeds from any claim that I may have for injuries. Such assignment hereby authorizes direct payment to Elgreat Healthcare Center under and/or from any such policy of insurance or proceeds. I certify that I have reviewed this document in full, understand its terms, and have had the opportunity to ask questions regarding its contents. I understand that this document is valid and remains in effect unless revoked in writing by me.