PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby give my consent for Christie Care, LLC (includes all medical staff) to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). The Notice of Privacy Practices provided by Christie Care, LLC below, describes such uses and disclosures more completely.
I have the right to review the Notice of Privacy Practices (included below) prior to signing this consent. Christie Care, LLC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Christie Pinolini MSN, FNP-BC at the office address. With this consent, Christie Care may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out administrative services such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, Christie Care, LLC may mail to my home or other alternative location any items that assist the practice such as appointment reminder cards, patient statements, lab kits.
With this consent Christie Care, LLC may e-mail to my home or other alternative location any items that assist efficiency in practice, such as appointment reminder cards, patient statements and lab requisitions. I have the right to request that Christie Care, LLC restrict how it uses or discloses my PHI. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
Acknowledgement of Receipt of Notice
By signing this form, I am consenting to allow Christie Care, LLC to use and disclose my PHI in the above stated manner and I acknowledge that I have received e copy of the Notice of Privacy Practices (HIPAA compliance) via email below. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Christie Care, LLC may decline to provide treatment to me.
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NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice tells you about the ways Christie Care, LLC may collect, store, use and disclose your protected health information and your rights concerning your protected health information. “Protected Health Information” is information about you that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for that care.
Federal and state laws require us to provide you with this Notice about your rights and our legal duties and privacy practices with respect to your protected health information. We must follow the terms of this Notice while it is still in effect. Some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards.
Uses and Disclosures of Your Protected Health Information
We may use and disclose your protected health information for different purposes. The examples below are illustrations of the different types of uses and disclosures that we may make without obtaining your authorization.
- Payment. We may use and disclose your protected health information in order to pay for your covered health expenses. For example, we may use your protected health information to process claims or be reimbursed by another insurer that may be responsible for payment.
- Treatment. We may use and disclose your protected health information to assist your other health care providers in your diagnosis and treatment.
- Health Care Operations. We may use and disclose your protected health information in order to perform various operational activities.
- Enrolled Dependents and Family Members. We will mail explanation of benefits forms and other mailings containing protected health information to the address we have on record for you.
Other Permitted or Required Disclosures
- As Required by Law. We must disclose protected health information about you when required to do so by law.
- Public Health Activities. We may disclose your protected health information to public health agencies for reasons such as preventing or controlling disease, injury or disability.
- Victims of Abuse, Neglect or Domestic Violence. We may disclose your protected health information to government agencies about abuse, neglect or domestic violence.
- Health Oversight Activities. We may disclose protected health information to government oversight agencies (e.g. state insurance departments) for activities authorized by law.
- Judicial and Administrative Proceedings. We may disclose protected health information in response to a court or administrative order. We may also disclose protected health information about you in certain cases in response to a subpoena, discovery request or other lawful process.
- Law Enforcement. We may disclose protected health information under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime.
- Coroners or Funeral Directors. We may release protected health information to coroners or funeral directors as necessary to allow them to carry out their duties.
- Research. Under certain circumstances, we may disclose protected health information about you for research purposes, provided certain measures have been taken to protect your privacy.
- To Avert a Serious Threat to Health or Safety. We may disclose protected health information about you, with some limitations, when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
- Special Government Functions. We may disclose information as required by military authorities or to authorized federal officials for national security and intelligence activities.
- Workers’ Compensation. We may disclose protected health information to the extent necessary to comply with state law for workers’ compensation programs.
Other Uses or Disclosures With an Authorization
Other uses or disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke an authorization at any time in writing, except to the extent that we have already taken action on the information disclosed or if we are permitted by law to use the information to contest a claim or coverage under the Plan.
Your Rights Regarding your Protected Health Information
You may have certain rights regarding protected health information that our practice maintains about you.
- Right To Access Your Protected Health Information. You have the right to review or obtain copies of your protected health information records, with some limited exceptions. Usually the records include billing, claims payment and case or medical management records. Your request to review and/or obtain a copy of your protected health information must be made in writing. We may charge a fee for the costs of producing, copying and mailing your requested information, but we will tell you the cost in advance.
- Right to Amend Your Protected Health Information. If you feel that your protected health information maintained by Christie Care, LLC is incorrect or incomplete, you may request that we amend the information. Your request must be made in writing and must include the reason you are seeking a change. We may deny your request, if for example, you ask us to amend information that was not created by Christie Care, LLC or you ask us to amend a record that is already accurate and complete. If we deny your request to amend, we will notify you in writing. You then have the right to submit to us a written statement of disagreement with our decision and we have the right to rebut that statement.
- Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures we have made of your protected health information. The list will not include our disclosures related to your treatment, our payment or health care operations, or disclosures made to you or with your authorization. The list may also exclude certain other disclosures, such as for national security purposes. Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. This time period may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (paper or electronically). For additional lists within the same time period, we may charge for providing the accounting, but we will tell you the cost in advance.
- Right to Request Restrictions on the Use and Disclosure of Your Protected Health Information. You have the right to request that we restrict or limit how we use or disclose your protected health information for treatment, payment or health care operations. We may not agree to your request. If we do agree, we will comply with your request unless the information is needed for an emergency. Your request for a restriction must be made in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit how we use or disclose your information, or both; and (3) to whom you want the restrictions to apply.
- Right to Receive Confidential Communications. You have the right to request that we use a certain method to communicate with you or that we send information to a certain location if the communication could endanger you. Your request to receive confidential communications must be made in writing. Your request must clearly state that all or part of the communication from us could endanger you. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
- Right to a Paper Copy of This Notice. You have a right at any time to request a paper copy of this Notice, even if you had previously agreed to receive an electronic copy.
- Contact Information for Exercising Your Rights. You may exercise any of the rights described above by contacting our privacy office. See the end of this Notice for the contact information.
Health Information Security
Christie Care, LLC requires its employees to follow its security policies and procedures that limit access to health information about patients to those employees who need it to perform their job responsibilities. In addition, Christie Care, LLC maintains physical, administrative and technical security measures to safeguard your protected health information.
Changes to This Notice
We reserve the right to change the terms of this Notice at any time, effective for protected health information that we already have about you as well as any other information that we receive in the future. We will provide you with a copy of the new Notice whenever we make a material change to the privacy practices described in this Notice. Any time we make a material change to this Notice, we will promptly revise and issue the new Notice with the new effective date.
Complaints
If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may file a complaint with us by contacting the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request.
We support your right to protect the privacy of your protected health information. We will not retaliate against you or penalize you for filing a complaint.
Our Legal Duty
We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice.
If you have any questions or complaints, please contact:
Christie Pinolini MSN, FNP-BC
3545 SW Corporate Parkway
Palm City, Florida 34990