YOUR PRIVACY & HEALTH INFORMATION
You have privacy rights under a federal law that protects your health information. These rights are important for you to know. Federal law sets rules and limits on who can look at and receive your health information.
Our Physicians, Nurses, Billing Staff, clerical staff, and any other staff must follow this law. Information that is protected includes:
Any information that is put into you medical records
Conversations that the physician has with nurses and others regarding your care or treatment
Information about your health insurance
Billing about your visit at this clinic.
You have rights about your health information that includes the following:
To see and get a copy of you health records (copies may come with a fee)
Have corrections added to your health information
Receive a notice that tells you how your health information may be used and shared
Decide if you want to give your permission before our health information can be used or shared for certain purposes, such as marketing.
Get a report on when and why your health information was shared for certain purposes
File a complaint.
To make sure that your health information is protected in a way that doesn't interfere with your healthcare, your information can be used and share in the following way:
For your treatment and care coordination
To pay doctors and hospitals for your healthcare and help run their businesses
With your family, relatives, friends or others that you identify who are involved with your healthcare or your health care bills, unless you object.
To make sure doctors give good care
To protect the public's health, such as by reporting when the flu is in your are
Without your written permission, your provider cannot:
Give your health information to your employer
Use or share your health information for marketing or advertising purposes
Share private notes about your mental health counseling sessions
If you believe your health information was used or shared in a way that is not allowed under the privacy law, or if you weren't able to exercise your rights, you can file a complaint with your provider or health insurer. You also can file a complaint with the U.S. Government.
LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENT
In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly (to the insurance company listed below) benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic.I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments.
I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions.
I hereby convey to the above named provider to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor’s expenses.
This lifetime assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement.