New Patient Intake Form

PRIVACY POLICY

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices ("Notice") describes the medical information practices of BRIAN F. SWEENEY JR MD PC. BRIAN F. SWEENEY JR MD PC is considered a covered entity, and therefore is required by law to maintain the privacy of personal health information and to provide you with notice of our legal duties and privacy practices with respect to personal health information. All of BRIAN F. SWEENEY JR MD PC departments or programs are covered by this Notice and your personal health information may be shared among these divisions.

Our Pledge Regarding Medical Information

We understand that medical information about your health is personal. We will not disclose your personal health information to others unless you tel1 us to do so, or unless the law authorizes or requires us to do so. This Notice applies to all of the medical records we maintain. It describes the ways in which we may use and disclose medical information, and describes our obligations with regard to such information.

We are required by law to: • Keep your protected health information private; • Provide notice of our legal duties and privacy practices with respect to protected health information; • Notify affected individuals following a breach of unsecured protected health information; • Give you this Notice; and • Follow the terms of the Notice currently in effect.

We have the right to change our practices regarding the personal health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of the Notice by cal ling the Privacy Officer at 907-562-2928, or stopping by the Privacy Officer’s office at 4048 LAUREL STREET, SUITE 301, ANCHORAGE, ALASKA 99508.

How We May Use/Disclose Your Medical Information

The following are some of the d different ways that we may use and disc lose your personal health information:

For Treatment. We may use or disclose medical information about you to facilitate treatment, rehabilitation or treatment through services provided by BRIAN F. SWEENEY MD PC. For example, we may disclose medical information to other healthcare providers who are involved in taking care of you.


For Payment. We may use and disclose medical information about you to get reimbursed fot the services we provide to you, including such things as submitting bil1s to insurance companies (either directly or through a third party billing company), medical necessity determinations and reviews, and collection of outstanding accounts.

For Health Care Operations. We may use and disclose medical information about you for other BRIAN F. SWEENEY JR M D PC health care operations necessary to run BRIAN F. SWEENEY JR MD PC. For example, we may use medical information in connection with: conducting quality assessment and improvement activities; licensing; personnel training programs; fraud and abuse detection programs; and general BRIAN F. SWEENEY JR MD PC administrative activities

To Business Associates. There are some services provided to BRIAN SWEENEY JR MD PC through contracts with business associates. Examples include accounting, legal, training, and consulting services. Information shall be made available to business associates consistent with their need to know for purposes of providing services.

Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.

As Required by Law. We will disclose medical information about you when required to do so by federal, state or local law. For example, we may disclose medical information when required by a court order.

To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Other Uses and Disclosures

We may also use and disclose your health information in the following circumstances, when permitted by law, and with only the minimum necessary information being disclosed: • Appointment reminders • Language interpreters • Information about available treatments or products • Funeral Directors/Coroners/State Medical Examiners • Workers’ Compensation • Correctional Institutions (if you are in jail or prison) • Law Enforcement • Tissue and organ donation • Disaster relief • Military and Veterans (if you are an armed forces member) • Responses to legally compliant court orders • National security

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization. This includes the use or disclosure of psychotherapy notes, the use or disclosure of PHI for marketing, or the sale of PHI, which will require your express written authorization.
Your Rights Regarding Personal Health Information
You have the following rights regarding medical information we maintain about you:
• Right to Inspect and Copy. You may come to our offices and inspect and copy most of the medical information about you that we maintain. We will normally provide you with access to, or copies of, this information within 30 days of your request. We may also charge you a reasonable fee for you to copy any medical information that you have the right to access. If your records are held in electronic format, you may also obtain an electronic copy if it is reasonably available. In limited circumstances, we may deny you access to your medical information, and you may appeal certain types of denials.

• Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, your request must provide a supporting reason, be made in writing, and be submitted to the Privacy Officer. If we agree to amend the information, we will generally amend your information within 60 days of your request and will notify you when we have amended the information

We may deny your request for an amendment if does not meet the requirements listed above. In addition, we may deny your request if you ask us to amend information that: is not kept by or for BRIAN F. SWEENEY MD PC and/or MICHELLE RANDOLPH MD PC; was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete.

• Right to an Accounting of Disclosures. You have the right to request a list of disclosures, where such disclosure was made for any purpose other than treatment, payment or health care operations. We are not required to give you an accounting of information we have shared with our business associates or for which you have given us a written authorization.

To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer. Your request must state a time period, which may not be longer than six years or before April 14, 2003. Your request should indicate in what form you want the list (i.e. paper or electronic). The first list you request within a 12-month period will be free, and you may be charged for the cost of any additional lists. We will notify you of the cost and you may choose to withdraw or modify your request before any costs are incurred.

• Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a transport or treatment we provided. We are not required to agree to your request unless the disclosure is to a health plan for purposes of carrying out payment or health care operations (not treatment purposes) and the information pertains solely to an item or service paid for fully out of pocket.

WE UNDERSTAND YOU MAY HAVE CONCERNED RELATIVES OR SIGNIFICANT OTHERS. PLEASE LIST NAMES OF THOSE PEOPLE THAT WE MIGHT SHARE YOUR MEDICAL INFORMATION WITH. WITHOUT YOUR WRITTEN CONSENT, THIS INFORMATION WILL NOT BE RELEASED.

If you have a durable power of attorney please provide a copy to us.

By my signature below, I acknowledge that I have received BRIAN F. SWEENEY JR MD PC Notice of Privacy Practices and Client Rights, and that I understand and have had an opportunity to ask questions about the Notice.

This acknowledgement page will be retained in patient’s record. If acknowledgement could not be obtained from patient, the reasons must be documented please contact us so we can acknowledge why it is the case.

I REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE AND/OR OTHER INSURANCE COMPANY BENEFITS BE MADE TO BRIAN F. SWEENEY JR, MD ON MY BEHALF, FOR ANY SERVICES FURNISHED TO ME BY BRIAN F. SWEENEY JR, MD. REGULATIONS PERTAINING TO MEDICARE ASSIGNMENT OF BENEFITS APPLY. I AUTHORIZE BRIAN F. SWEENEY JR MD TO RELEASE ANY MEDICAL INFORMATION REQUIRED BY MY INSURANCE CARRIER FOR THE PROCESSING OF ALL MEDICAL CLAIMS FILED ON MY BEHALF.

I UNDERSTAND THOSE CHARGES THAT ARE NOT COVERED BY MY INSURANCE ARE MY OWN RESPONSIBILITY.

Telemedicine involves the use of electronic communications to enable healthcare providers and patients at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
•Patient medical records
•Medical images
•Live two-way audio and video
•Output data from medical devices and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Expected Benefits:
•Improved access to medical care by enabling a patient to remain in his/her local healthcare site (i.e. home) while the physician consults and obtains test results at distant/other sites.
•More efficient medical evaluation and management.
•Obtaining expertise of a specialist.
Possible Risks:
As with any medical visit, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
•In rare cases, the consultant may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient, or at least a rescheduled video consult;
•Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
•In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
•In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
By signing this document you acknowledge that you understand and agree with the following:
1.I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my written consent.
2.I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3.I understand the alternatives to telemedicine consultation, including an in person visit, have been explained to me. In choosing to participate in a telemedicine consultation, I understand that some parts of
4.the exam involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of the consulting healthcare provider.
5.I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6.I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
7.I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my healthcare provider and consulting healthcare provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time.

Patient Consent To The Use of Telemedicine

I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
I have read this document carefully and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.

Please also send us a copy of a photo ID and insurance card back and front. We need this to be able to bill your insurance. We will also be sending you an e-mail with documents for electronic signature if we have not already. Thank you for choosing us for you Gastroenterology needs.