RELEASING INFORMATION AND PATIENTS RIGHTS
The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy and is only to be used or shared in the minimum necessary fashion, healthcare providers are to obtain their patient´s consent for uses and disclosure of health information about the patient to carry out treatment, payment, or health care operations. By signing this consent, you understand that your physician may need to provide necessary medical information to other appropriate physicians, pharmacies, hospital, insurance companies, laboratories and billing agencies. Refusing to consent to the use or disclosure of your Personal Health Information prohibits the doctor from billing for their services; scheduling your care at hospital; or calling in a prescription to a pharmacy; or medical need. Under this law we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke any actions that have already been taken which relied on this or a previously signed consent.
If you have any objections to this form, please ask to speak with our Office Manager.
COMPLIANCE ASSURANCE NOTIFICATION FOR OUR PATIENT´S
The misuse of PHI has been identified as a national problem causing patient´s inconvenience, aggravation and money. We want you to know that all of our employees, managers and doctors continually undergo training so that they may understand and comply with government regulation regarding the HIPPA with particular emphasis on the “Privacy Rule” we strive to achieve the very highest standards of ethics and integrity in performing service four our patient. It is our policy properly determines appropriate use of PHI in accordance with the governmental rules, laws and regulation. We want to ensure that our practice never contributes in any way to the growing problem of improper disclosure of PHI. As part of this plan, we have implemented a Compliance Program that we believe will help us prevent any inappropriate use PHI. We also know that we are not perfect. Because of this fact, our policy is to listen to our employees and our patients without any thought of penalization if they feel than an even in any way compromises our policy of integrity. More so, we welcome your input regarding any service problem so that we may remedy the situation promptly.
Thanks you for being one of our highly valued patients.
NOTICE OF PRIVACY PRACTICES – HIPPA
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The privacy of your medical information is important to us. We understand that you medical information is personal and we are committed to protecting it. We create a record of the care and services you received at our organization. We need this record to provide you with quality care and to comply with certain legal requirement. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.
Law Requires Us to:
1. Keep your medical information private.
2. Give you this notice describing your legal duties, privacy practices, and your rights regarding your medical information.
3. Follow the terms of the current notice.
We Have the Right to:
1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law.
2. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.
Notice of Change to Privacy Practices:
Before we make an important change in our privacy practices we will change this notice and make the new notice available upon request. The following section describes different ways that we use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below without your specific written authorization. Any specific written authorization you provided may be revoked at any time by writing to us at the address provided at the end of this notice.
For Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. We may also share medical information about you to your other health care providers to assist them in treating you.
For Payment: We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information.
For Health Care Operations: We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluation the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve your.
Additional Ones And Disclosure: In addition to using and disclosing your medical information for treatment, payment, and health care operation, we may use and disclose medical information for the following purposes.
Notification: We may use and disclose medical information to notify or help notify, a family member, your personal representative or another person responsible, for your care. We will share information about your location, general condition, or death. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-ray or medical information for you.
Disaster Relief: We may share medical information with a public or private organization or person who can legally assist in disaster relief efforts.
Fundraising: We may provide medical information to one of our affiliated fundraising foundations to contact you for fundraising proposes. We will limit our use and sharing to information that describes you in general, not personal, terms and the dates of your health care. In any fundraising materials, we will provide you a description of how you may chose not to receive future fundraising communications.
Research in Limited Circumstances: We may use medical information for research purposes in limited circumstance where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of medical information.
Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and other law enforcement custodial situations, and for government programs providing public benefits.
Court Orders and Judicial and Administrative Proceedings: We may disclose medical information in response to a court or administrative order, warrant, or grand subpoena, under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials. We may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness crime victim or missing person.
Public Health Activities: As required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.
Victims of Abuse, Neglect or Domestic Violence: We may use and disclose medical information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence, or the possible victim of other crimes. We may share your medical information if it is necessary to prevent a serious threat to your health or safety, or the health or safety of others. We may share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody.
Workers Compensation: We may disclose health information when authorized or necessary to comply with law relating to workers compensation or other similar programs.
Health Oversight Activities: We may disclose medical information to health oversight agency for, audits, investigations or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs and compliance with civil rights laws.
Law Enforcement: Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.
Appointment Reminders: We may use and disclose medical information for purposes of sending you appointment postcards or otherwise reminding you of your appointments.
You Have a Right to:
1. Look at or get copies of certain parts of your medical information. You may request that we provide copies in a formal other than photocopies. We will use the format you request unless. It is not practical for us to do so. You must make your request in writing. You may get the form to request access by using the contact information listed at the end of this notice. You may also request access by sending a letter to the contact person listed at the end of this notice. If you request copies, we will charge you $ for each page, and postage if you want the copies mailed to you. Contact us using the information listed above of this notice for a full explanation of our fee structure.
2. Receive a list of all the times we or our business associates shared your medical information for purposes other than treatment, payment, and health care operations and other specified exceptions.
3. Request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency).
4. Request that we communicate with you about your medical information by different means or to different locations. Your request that we communicate your medical information to you different means or at different locations must be made in writing to the contact person listed at the end of this notice.
5. Request that we change certain parts of your medical information. We may deny your request if we did not create the information you want changed or for certain others reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If we accept your request to change the information, we will make reasonable efforts to tell others. Including people you name of the change and to include the changes in any future sharing of that information.
6. If you have received this notice electronically, and wish to receive a paper copy, you have the right to obtain a paper copy by making a request in writing to the contact person listed at the end of this notice.
If you have any questions about this notice or if you think that we have violated your privacy rights, please contact us. You may also submit a written complaint to the U.S. Department of Health and Human Services.
THE FOLLOWING ARE THE RESPONSIBILITIES OF EACH PATIENT:
1. A patients has the responsibility to provide the best of his/her knowledge, accurate and complete information about present complaints, past illness, hospitalizations, medications and other matters relating unexpected changes in his/her condition to the responsible practitioner. A patient is responsible for making it know whether he/she clearly comprehends a contemplated course of action and what is expected of him/her.
2. A patient is responsible for the following treatment plan recommended by the practitioner primarily responsible for the following treatment plan recommended by the practitioner primarily responsible for his/her care. This may include following the instruction of nurses and other professional staff as they carry out the coordination of he plan of care and implement the responsible practitioner´s orders as they enforce the facility´s rules and regulations.
3. The patient is responsible for keeping appointments and when he/she is unable to do so for any reason, to notify the clinic.
4. The patient is responsible for his/her actions when he/she refuses treatment or does not follow the practitioner instructions.
5. The patient is responsible for assuring the financial obligation of his/her health care fulfilled as promptly as possible.
6. The patient is responsible for the following the clinic´s rules and regulations affecting care and conduct.
7. The patient is responsible for being considerate of the right of other patients and clinic personnel and the assisting in the control of noise.
8. The patient is responsible for being respectful of the property of persons and of the clinic.
9. The patient is responsible for holding in strict confidence other patient´s mental health information, which may be obtained during group therapy and socialization.
• All information shared by patient in group therapy sessions is strictly confidential and can not be disclosed outside of the group without voluntary written authorization of the appropriate patient/s.
• Unauthorized disclosure of mental health information violates provisions of State Laws.
• Unauthorized disclosure may result in civil liability. Penalties include money damages, fines and/or imprisonment.
CONSENT FOR DIAGNOSTIC AND/OR THERAPEUTIC AND/OR LABORATORY PROCEDURES
I hereby consent to and authorize Vidamax Medical Center and any other health professional to perform a physical examination and routine diagnostic procedure upon me.
I also consent to and authorize Vidamax Medical Center to prescribe therapeutic regime which I shall follow.
Unless I explicitly refuse, I consent that the diagnostic procedures ordered by Vidamax Medical Center be performed on me despite the risk involved and complications that might be involved which were explained to me at the time they were ordered.
NOTICE TO PATIENTS
Under Florida law, physicians are generally required to carry malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for Medical Malpractice.
Your Physician has decided not to carry Medical Malpractice Insurance. This is permitted under Florida law subject to certain conditions. Florida law imposed penalties against non-insured Physician/or Medical Center who fail to satisfy adverse judgments raisins from claims of medical malpractice, this notice is provided pursuant to Florida Law.
Under Florida law grants every adult 18 years and older have the right to make certain decisions about his or her medical treatment. You have the right, under certain conditions, to decide whether to accept or reject medical treatment and other procedures that would prolong your life artificially. The law ensures your rights and personal wishes are respected even if you are too sick to make your own decisions.
EVERY ADULT SHOULD READ AND SIGN THIS PAGE INFORMATION