PATIENT'S BILL OF RIGHTS, PATIENT'S RESPONSIBILITIES, AND HIPAA NOTICE OF PRIVACY PRACTICES

PATIENT'S BILL OF RIGHTS

Our practice adheres to the following Patient’s Bill of Rights. The patient has the right to:

Considerate and respectful care.
Knowledge of the name of the provider who has primary responsibility for coordinating the care and the names and professional relationships of other providers who will see the patient.
Receive as much information about any proposed treatment or procedure as the patient may need in order to give informed consent or to refuse this course of treatment. Except in emergencies, this information includes a description of the procedure or treatment, the medically significant risks involved in this treatment, alternate courses of treatment or non-treatment and the risks involved in each and to know the name of the person who will carry out the procedure or treatment.
Participate actively in any decisions regarding mental health and medical care, to the extent permitted by law. This includes the right to refuse treatment.
Full consideration of privacy concerning the mental health and medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. The patient has the right to be advised as to the reason for the presence of any individual.
Confidential treatment of all communications and records pertaining to his/her care.
Be advised if the provider proposes to engage in or perform human experimentation affection care or treatment. The patient has the right to refuse to participate in such research projects.
Have all patient’s rights apply to the person wo may have legal responsibility to make decisions regarding medical care on behalf of the patient.
Have complaints forwarded to administrative personnel for appropriate response.
Know that all the Clinic/Office personnel will observe these patients’ rights.

PATIENT'S RESPONSIBILITIES

The care a patient receives depends partially on the patient. Therefore, in addition to these rights, a patient has certain responsibilities as well.

The patient has the responsibility to provide accurate and complete information concerning his/her present complaints, past medical and mental health history, and other matters related to his/her health.
The patient is responsible for making it known whether he/she clearly comprehends the course of his/her mental health and/or medical treatment and what is expected of him/her.
The patient is responsible for following the treatment plan established by his/her provider, including the instructions of nurses and other health professionals as they carry out the provider’s orders.
The patient is responsible for keeping appointments and notifying the office or provider when he/she is unable to keep the scheduled appointments.
The patient is responsible for his/her actions should he/she refuse treatment or not follow his/herproviders’ orders.
The patient is responsible for assuring that the financial obligations of his/her care are fulfilled.
The patient is responsible for being considerate of the rights of other patients and office personnel.

HIPAA 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 REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you, and that relates to your past, present, or future physical or mental health condition and related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your provider, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the provider’s practice, and any other use required by law.

To protect your privacy and comply with federal law, we only release medical records to verified parties with the appropriate legal authority. This may include your health plan or their designated representatives but only when proper privacy safeguards are in place.

Treatment:

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a provider to whom you have been referred to ensure that the provider/specialist has the necessary information to diagnose or treat you.

Payment:

Your protected health information will be used, as needed to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations:

We may use or disclose, as needed, your protected health information in order to support the business activities of your provider’s practice. These activities include, but are not limited to, quality assessment, employee review, training of students, licensing, fundraising, and conducting or arranging for other business activities. For example, we may disclose your protected health information to school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your provider. We may also call you by name in the waiting room when your provider is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you.

We may use or disclose your protected health information in the following situations without your authorization. These situations include as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization, or opportunity to object unless required by law. You may revoke the authorization, at any time, in writing, except to the extent that your provider or the provider’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS

The following are statements of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information (fees may apply) – Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of
confidentiality.

You have the right to request a restriction of your protected health information (fees may apply) – This means you may ask us not to use or disclose any part of your protected health information and by law we must comply when the protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full. You may also request that any part of your protected health information not to be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. By law, you may not request that we restrict the disclosure of your PHI for treatment purposes.

You have the right to request to receive confidential communications – You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e., electronically.

You have the right to request an amendment to 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 may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures – You have the right to receive an accounting of all disclosures except for the following disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of this request.

You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one.

COMPLAINTS

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.