The purpose of this consent form is to inform you, the patient, how your personal health information is used and /or disclosed by this provider or organization. We want you to be full aware of what we do with your information so that you can provide us with your consent in order for us to treat your health care needs, receive payment for services rendered, and allow administrative and other types of health care operations to happen, which are part of normal business activities of this provider or organization.
I understand that as part of my health care, this organization originates and maintains health records describing my health history, symptoms, test results, diagnoses, treatment, and plans for future care or treatment. I understand that 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/es and other health information to my bill(s).
- A means by which my health plan or health insurance company can verify that services billed were actually provided.
- A tool for routine health care operations in this organization, such as ensuring that we have quality processes and programs in place and making sure that the professionals who provide your care are competent to do so.
I understand that:
- I have been provided with a Notice of Privacy Practices that provides specific examples and descriptions of how my personal health information is used and disclosed by Parker Family Care™;
- I have the right to review the Notice of Privacy Practices prior to signing this consent;
- Parker Family Care™ can change its Notice of Privacy Practices but must notify me of those changes before they are put into practice and will mail me a copy of the new Notice to the address that I have provided;
- I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations and that Parker Family Care™ is not required to agree to those restrictions;
- Any restrictions to which Parker Family Care™ agrees to will be respected;
- I may revoke this consent in writing at any time. Further, I am aware that Parker Family Care™ can proceed with uses and disclosures that pertain to treatment, payment, or healthcare issues that took place before the consent was revoked.
- The provider will provide treatment to me even if I do not sign the consent form.
To request a restriction on the use and disclosure of your personal health information related to your treatment, payment for service, or for the health care operations of Parker Family Care™, please do so after reading the Notice of Privacy Practices. You may use this consent form to request a restriction.
I request the following restrictions to the use of disclosure of my health information related to your treatment, payment for service, or for the health care operations of Parker Family Care™, please do so after reading the Notice of Privacy Practices. You may use this consent form to request a restriction.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO YOUR IDENTIFIABLE HEALTH INFORMATION.
A. OUR COMMITMENT TO YOUR PRIVACY.
Parker Family Care™ (PFC) is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and privacy practices concerning your identifiable health information. By law, we must follow the terms of the notice of privacy practices that we have in effect at the time.
To summarize, this notice provides you with the following important information:
- How we may use and disclose your identifiable health information
- Your privacy rights in your identifiable health information
- Our obligations concerning the use and disclosure of your identifiable health information
The terms of this notice apply to all records containing your identifiable health information that are created or retained by our practice. We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records our practice has created or maintained in the past, and for any of your records we may create or maintain in the future. Parker Family Care™ will post a copy of our current notice in our offices in a prominent location, and you may request a copy of our most current notice during any office visit.
B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Parker Family Care™ Office Manager, 303-805-CARE
C. WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS
The following categories describe the different ways in which we may use and disclose your identifiable health information.
1. Treatment. PFC may use your identifiable health information to treat you. For example, we may ask you to undergo laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. Many of the people who work for us may use or disclose your identifiable health information to others in your treatment. Additionally, we may disclose your identifiable health information to others who may assist in your care, such as other physicians or therapists.
2. Payment. PFC may use and disclose your identifiable health information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your identifiable health information to obtain payment from third parties who may be responsible for such costs, such as family members. Also, we may use your identifiable health information to bill you directly for services and items.
3. Health Care Operations. PFC may use and disclose your identifiable health information to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our organization may use your health information to evaluate the quality of care you received from us or to conduct cost-management and business planning activities for our practice.
1. Appointment Reminders. Our organization may use and disclose your identifiable health information to contact you and remind you of visits.
2. Health-Related Benefits and Services. PFC may use and disclose your identifiable health information to inform you of health-related benefits or services that may be of interest to you.
3. Release of Information of Family/Friends. Our organization may use and disclose your identifiable health information to a friend of family member who is helping you pay for your health care or who assists in taking care of you.
4. Disclosures Required by Law. Our organization may use and disclose your identifiable health information when we are required to do so by federal, state, or local law.
D. USE AND DISCLOSURE OF YOUR IDENTIFIABLE HEALTH INFORMATION IN CERTAIN SPECIAL CIRCUMSTANCES
The following categories describe unique scenarios in which we may use or disclose your identifiable health information:
a. Public Health Risks. PFC may use and disclose your identifiable health information to public health authorities who are authorized by law to collect information for the purpose of:
i. Maintaining vital records, such as births and deaths
ii. Reporting child abuse or neglect
iii. Preventing or controlling disease, injury, or disability
iv. Notifying a person regarding potential exposure to a communicable disease
v. Notifying a person regarding a potential risk for spreading or contracting a disease or condition
vi. Reporting reactions to drugs or problems with products or devices
vii. Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
viii. Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.
b. Health Oversight Activities. Our organization may use and disclose your identifiable health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the health care system in general.
c. Lawsuits and Similar Proceedings. Our organization may use and disclose your identifiable health information to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your identifiable health information n response to a discovery request, subpoena, or other lawful process by another party involved in the disputes, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
d. Law Enforcement. PFC may release identifiable health information if asked to do so by a law enforcement official:
i. Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
ii. Concerning a death believed to have been the result from criminal conduct
iii. Regarding criminal conduct at our offices
iv. In response to a warrant, summons, court order, subpoena, or similar legal process
v. To identify/locate a suspect, material witness, fugitive, or missing person
vi. In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)
e. Serious Threats to Health or Safety. Our organization may use and disclose your identifiable health information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
f. Military. PFC may use and disclose your identifiable health information if you are a member of US or foreign military forces (including veterans) and if required by the appropriate military command authorities.
g. National Security. PFC may disclose your identifiable health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your identifiable health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
h. Inmates. PFC may disclose your identifiable health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you; (b) for the safety and security of the institution; and/or (c) to protect your health and safety or the health and safety of other individuals.
i. Workers’ Compensation. PFC may release your identifiable health information for workers’ compensation and similar programs.
E. YOUR RIGHTS REGARDING YOUR IDENTIFIABLE HEALTH INFORMATION
You have the following rights regarding the identifiable health information that we maintain about you:
1. Confidential Communications. You have the right to request that PFC communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication please complete a new patient packet and indicate your preferences. We will accommodate reasonable requests. You do not need to give a reason for your request.
2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your identifiable health information for treatment, payment, or health care operations. Additionally, you have the right to request that we limit our disclosure of your identifiable health information to individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use of disclosure of your identifiable health information, you must make your request in writing to Zem Schluter, Office Manager, Parker Family Care™ 9397 Crown Crest Blvd, Ste 440, Parker, CO 80138 or contact Zem Schluter at 303-805-CARE for further information. Your request must describe in a clear and concise fashion: (a) the information you wish restricted; (b) whether you are requesting to limit our practice’s use, disclosure, or both; and (c) to whom you want the limits to apply.
3. Inspection and Copies. You have the right to inspect and obtain a copy of the identifiable health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Zem Schluter, Office Manager, Parker Family Care™ 9397 Crown Crest Blvd, Ste 440, Parker, CO 80138 in order o inspect and/or obtain a copy of your identifiable health information. Our organization may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be made in writing and submitted to Zem Schluter, Office Manager, Parker Family Care™ 9397 Crown Crest Blvd, Ste 440, Parker, CO 80138. You must provide us with a reason that supports your request for amendment. PFC will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is: (a) accurate and complete; (b) not part of the identifiable health information kept by or for the organization; (c) not part of the identifiable health information which you would be permitted to inspect and copy; or (d) not created by our organization, unless the individual or entity that created the information is not available to amend the information.
5. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain disclosure our organization has made of your identifiable health information. In order to obtain an accounting of disclosures, you must submit your request in writing to Zem Schluter, Office Manager, Parker Family Care™ 9397 Crown Crest Blvd, Ste 440, Parker, CO 80138. All requests for an “accounting of disclosures” must state a time period, which may not be longer than 6 years and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. PFC will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. A copy is included in New Patient packets. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Zem Schluter, Office Manager, Parker Family Care™ 9397 Crown Crest Blvd, Ste 440, Parker, CO 80138 or contact Zem Schluter at 303-805-CARE for further information.
7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our organization or with the Secretary of the Department of Health and Human Services. To file a complaint with our organization, contact Zem Schluter, Office Manager, Parker Family Care™ 9397 Crown Crest Blvd, Ste 440, Parker, CO 80138 or contact Zem Schluter at 303-805-CARE for further information. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
8. Right to Provide an Authorization for Other Uses and Disclosures. PFC will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your identifiable health information may be revoked at any time in writing. After information for the reasons described in the authorization. Please note, we are required to retain records of your care.