RELEASE OF INFORMATION
The above information is true to the best of my knowledge. I hearby grant permission to be contacted by Family Health Matters by phone, text or email regarding my request for COVID-19 appointment. I understand that a medical provider will first screen my symptoms via televisit and order the COVID-19 test if deemed appropriate.
Notice of Privacy Practices
This notice explains how medical information about you may be used and shared. It also explains how you can get a copy of this information. Please read it carefully.
If you have any questions about this notice, please call Isaias Paja, MD, Chief Medical Officer, Family Health Matters Community Health Center.
WHAT WE MUST DO:
By law, we must:
· Make sure that medical information that identifies you is kept private (with certain exceptions);
· Tell you about how we use and share medical information about you; and
· Follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND SHARE MEDICAL INFORMATION ABOUT YOU:
We use and share medical information for many reasons. Here are some examples:
For Treatment. We may use medical information about you to make sure you get the right medical treatment or services. We may share medical information about you with doctors, nurses, medical students, and others, including people outside our clinic, who are taking care of you. We only share this information with them if they need it to give you medical care.
For Payment. We may use and share medical information about you so that the treatment and services you get at Family Health Matters Community Health Center may be billed to you, an insurance company, or a third party. We may also inform your health plan about treatment you are going to receive so that we can make sure your plan will cover treatment.
For Health Care Operations. We may use and share medical information about you for health care operations. This means for running the clinic and making sure that all of our patients get the best care. For example, we may use medical information to look at how our staff is caring for you. We may also share information with other groups that have a relationship with you (for example your health plan), for their health care operations.
Appointment Reminders, Treatment Choices, and Health-Related Products and Services. We may use and share medical information to remind you of an appointment with us. We may use and share medical information to tell you about treatment choices or health-related products or services that may be of interest of you
Individual Helping with Your Care or Payment for Your Care. We may share medical information about you with a friend or family member who is helping with your medical care. We may also give information to someone who helps pay for your care. We may also share medical information about you in an emergency so that your family can be notified about your condition, status and location.
Research. Under certain circumstances, we may use and share medical information about you for research. For example, a research project may compare the health and recovery of all patients who received one medication to those who received another for the same condition. All research projects must get special approval. We check each research project and how it uses medical information to make sure the research does not take away patients’ need for privacy of their medical information. We may share medical information about you with people who are planning a research project to help them look for patients with specific medical needs, so long as the medical information they look at does not leave the clinic.
OTHER WAYS WE MAY USE OR SHARE YOUR MEDICAL INFORMATION:
As Required By Law. We will share medical information about you when we have to under federal, state, or local laws.
When there is a Serious Threat to Health or Safety. We may use and share medical information about you when there is a serious threat to your health and safety or the health and safety of the public or another person. The information would only be shared with someone who can help prevent the threat.
Business Reasons. We may share health information with our business partners that work with us or provide us with services. We will only share the information when it is needed. For example, we may share information with another company who does billing services for us. All of our business partners must protect the privacy of your information. They cannot use or share any information that is not part of our contract.
Organ and Tissue Donation. If you are an organ donor, we may share medical information to organizations that help with organ or tissue donation and transplantation.
Military and Veterans. If you are a member of the Armed Forces, we may share information about you with military command authorities if we are asked to do so. We may also share medical information about foreign military personnel to foreign military authorities.
Workers’ Compensation. We may share medical information about you for workers’ compensation or other programs. These programs provide benefits when an injury or illness happens at work or while you are doing your job.
Public Health Risks. We may share medical information about you when there may be a public health risk. This usually to prevent or control disease, injury, or disability. It can also be to report births and deaths; report the abuse or neglect of children, elders and dependent adults; report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or condition; and to notify the appropriate government for contracting or spreading a disease or condition; and to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only share this information if you agree to it or when we have to share it under law.
Health Oversight Activities. We may share medical information to a health oversight agency under the law. These oversight activities can include audits, investigations, inspections, and licensure. This allows the government to monitor the health care system, government programs, and make sure civil rights laws are followed.
Law and Disputes. If you are involved in a lawsuit or a dispute, we may share medical information about you if we are given a court or administrative order. We may also share medical information about you in response to a subpoena, discovery request, or other reason. We must first try to contact you to tell you about the request (which may include written notice to you) or to order protecting the information requested.
Law Enforcement. We may share medical information if asked to do so by a law enforcement official if the information is: 1) in response to a court order, subpoena, warrant, summons, or similar process; 2) to identify or locate a suspect, a suspect, fugitive, material witness, or missing person; 3) about the victim of a crime if, under certain limited circumstances, we are unable to obtain the criminal conduct at the clinic; and 6) in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors. We may share medical information about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also share medical information with funeral directors when needed.
National Security and Intelligence. We may share medical information about you to federal officials for intelligence, counterintelligence, and other national security reasons under the law.
Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of law enforcement, we may share medical information about you (1) so you can get health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
Rights about Your Medical Information
When it comes to health information we have about you, you have these rights:
Right to View and Copy. You have the right to view and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but may not include some mental health information. You must write us a letter asking to view and obtain a copy of your medical information.
Right to Amend. If you feel that the medical information we have about you is incorrect or incomplete, you may ask us to fix the information. You have the right to ask as long as the information is kept by our clinic. You may write us a letter asking to fix your medical information.
Right to Know Who has Seen Your Information. You have the right to ask for a list of all the people and organizations that have seen or used your medical information. You must write us a letter asking for this list.
Right to Limit Your Information. You have the right to ask us to limit the medical information we use or share about you for treatment, payment or health care operations. You also have the right to limit the medical information about you that we share with someone who is helping with your care or payment for your care. For example, you could ask that we not share information about a surgery you had. You must write us a letter asking us to limit your medical information. We may not be able to limit your information if it is needed for emergency treatment.
Right to Ask for Private Communications. You have the right to ask that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. You must tell us how or where you wish to be contacted. We will try to honor your wishes.
Right to a Paper Copy of This Notice. You have the right to a paper of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you can still ask for a paper copy of this notice.
Changes To This Notice. We can change this notice at any time. Any changes can be about medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice on our clinic. The notice will have effective date on the first page.
COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint Family Health Matters Community Health Center or with the Secretary of the Dept. of Health and Human Services. To file a complaint with our Clinic, contact our Chief Medical Officer, Family Health Matters, 901 W. Orangethorpe Avenue, Fullerton, CA 92832, (714) 441-0411. All complaints must be submitted in writing. If you file a complaint, we will not treat you differently.
By signing this form, I acknowledge receipt of the Notice of Privacy Practices. The Notice of Privacy Practices provides information about how we use and disclose your protected health information. We encourage you to read it in full. Notice of Privacy is subject to change. If we change the notice you may obtain a copy of the revised notice by contacting our HIPAA Officer. If you have any questions about the Notice of Privacy Practices please contact the HIPAA Officer at (714) 441-0411.
CONSENT TO TREATMENT
CONSENT TO TREATMENT: The undersigned hereby consent to the administration and performance of all diagnostic procedures and treatments, which, in the judgment of North Orange Regional Health Foundation (Family Health Matters Community Health Center), may be considered necessary or advisable.
I further agree that if I decide to leave the office without the written consent of the physician/provider, I shall be totally liable for the consequences of such decision.
CONSENT TO TREATMENT VIA TELEHEALTH: The undersigned hereby consent to services delivered via telephone and video conference, as allowed.
CONSENT TO REVIEW MEDICATION HISTORY FROM THIRD PARTY SOURCES: The undersigned hereby provide Family Health Matters (FHM) consent to obtain and review your medication history.
A prescription history is a list of medications that we or other healthcare providers have prescribed for you. This list is collected from different sources, including your pharmacy and your health insurance.
A detailed prescription history will improve the accuracy of our prescription list in your medical record and will be used for treatment purposes.
I have read and understood the consent to obtain prescription history.