Notice of Privacy Practice Acknowledgement and Release of Information Authorization
Our notice of Privacy Practices describes in more detail how your protected health information may be used and disclosed and how you can access your information. Please ask to see a copy of this document at any time. You have a right to review the notice before signing this consent. The terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting our office.
We keep a record of the health care service we provide you. You may ask to see and copy the record and you may ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. We are not required to agree with this restriction, but if we do, we shall honor that agreement. You have a right to revoke this consent in writing, signed by you. However such revocation shall not affect any disclosures we have already made in reliance to your prior consent.
Further, I authorize Dr. Brar and staff (North Sound Oral and Facial Surgery P.S.), as needed, to discuss my health care, treatment, and financial arrangements with the individuals indicated below:
Anyone in my immediate family My Children/Stepchildren
My Mother/ Stepmother/Guardian My Employer
My Father/Stepfather/Guardian My Escort (health care attendant)
My Insurance Company (s) Other: ______________________________
Individual Transporting me after surgery (pertinent health and treatment information only)
I give permission for Dr. Brar’s office (North Sound Oral and Facial Surgery P.S.) to leave a detailed message about my upcoming appointment, including time, date, and medications needed, with someone at my home, or on my voicemail.
Or on a voicemail at my place of employment
Or on my cellular telephone
By my signature below, I acknowledge receipt of this disclosure and authorize discussion of my health care and related issues as indicated above.
Patient Name (please print) Date
Signature of patient (or legally authorized individual) Printed name of signer (if not patient)
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE READ IT CAREFULLY
The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a Federal program that requests that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, the right to understand and control how your personal health information (“PHI”) is used. HIPAA provided penalties for covered entities that misuse personal health information.
As required by HIPAA, we have prepared this explanation of how we are to maintain the privacy of your health information and how we may disclose your personal information.
We may use and disclose your medical records only for each of the following purposes; treatment, payment and health care operation.
· Treatment means providing, coordinating, or managing health care and related services by one or more healthcare providers. An example of this would include referring you to a retina specialist.
· Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. An example of this would include sending your insurance company a bill for your visit and/or verifying coverage prior to a surgery.
· Health Care Operations include business aspects of running our practice, such as conducting quality assessments and improving activities, auditing functions, cost management analysis, and customer service. An example of this would be new patient survey cards.
· The practice may also disclose your PHI for law enforcement and other legitimate reasons although we shall do our best to assure its continued confidentiality to the extent possible.
We may also create and distribute de-identified health information by removing all reference to individually identifiable information.
We may contact you, by phone or in writing, to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Any other uses and disclosures will be made only with your written authorization under certain circumstance. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
You may have the following rights with respect to your PHI.
· The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures of family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to honor a request restriction except in limited circumstances which we shall explain if you ask. If we do agree to the restriction, we must abide by it unless you agree in writing to remove it.
· The right to reasonable requests to receive confidential communications of Protected Health Information by alterative means or at alternative locations.
· The right to inspect and copy your PHI.
· The right to amend your PHI.
· The right to receive an accounting of disclosures of your PHI.
· The right to obtain a paper copy of this notice from us upon request.
· The right to be advised if your unprotected PHI is intentionally or unintentionally disclosed.
We are required by law to maintain the privacy of your Protected Health Information and to provide you the notice of our legal duties and our privacy practice with respect to PHI.
Other Disclosures and Uses
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.
Communication with Family
Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency.
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.
As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Abuse & Neglect
We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.
If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals.
We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in custody of law enforcement.
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.
We may disclose your protected health information in the course of any judicial or administrative proceedings as allowed or required by law, with your consent, or as directed by a proper court order.
We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.
If we maintain a website that provides information about our entity, this Notice will be on the website.
This notice is effective as of July 01, 2011 and it is our intention to abide by the terms of the Notice of Privacy Practices and HIPAA Regulations currently in effect. We reserve the right to change the terms of our Notice of Privacy Practice and to make the new notice provision effective for all PHI that we maintain. We will post and you may request a written copy of the revised Notice of Privacy Practice from our office.
You have recourse if you feel that your protections have been violated by our office. You have the right to file a formal, written complaint with office and with the Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint.
Feel free to contact the Practice Compliance Officer for more information, in person or in writing.