Health Brigade HIPAA Privacy Agreement

Health Brigade HIPAA Privacy Agreement
I acknowledge that I have received the HIPAA Notice of Privacy Practice. I also understand that I may obtain a copy of the protected health information described in this consent
Signature of Patient *

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Signature of Person Obtaining Consent

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Consent to Receive Health Care Reminders
Health Brigade does not charge for this service, but standard text messaging rates may apply based on your wireless plan. I understand that this consent will apply to all future communication unless I request a change in writing.

I consent to receive text messages on my cellphone to remind me of an appointment, and I also agree to inform the Health Brigade if my cellphone number changesI consent to receive voicemails regarding my appointment times, medications, and/or lab resultsI do not consent to receive text messages to remind me of an appointmentI do not consent to receive voicemails regarding my appointment times, medications and/or lab results.
Please Initial*

Consent to Share Health Information (List up to 3 people)

	Name	Relationship	Phone Number
Person 1
Person 2
Person 3

I give permission to discuss and share information regarding my care to those listed above. (Lab results, appointment reminders, medication pick up, etc.)

I understand that this consent will remain in effect for one year and may be revoked at any time.
Signature of Patient *

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Signature of Person Obtaining Consent

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Health Brigade HIPAA Notice of Privacy Practice

The HIPAA Privacy Rule, a Federal law, gives you rights over your health information and sets rules and limits on who can look at and receive your health information. The Privacy Rule applies to all forms of a person’s protected health information, whether electronic, written, or oral.

Your health records include:
- Information your doctors, nurses, and other health care providers put in your medical record.
- Conversations your doctor has about your care or treatment with nurses and others.
- Information about you in your health insurer’s computer system.
- Most other health information about you held by those who must follow these laws
Your Rights to Your Health Information
- The right to see or get a copy of your health information. Ask us how to do this.
- The right to request a change if you feel the information in your health record is incorrect or incomplete. We may say “no” to this request, but if we do, we will tell you why in writing within 60 days.
- The right to ask us to limit what health information we share. We are not required to agree to this request, and we may say “no” if it would affect your care.
- The right to request confidential communications – you can ask us to contact you in a specific way, such as by home or office phone number.
- The right to a list of those with whom we’ve shared your health information over the past 6 years prior to when you make the request.
- The right to choose someone to act for you, such as a legal guardian, and to choose who you would like us to share information with, such as a family member.
- The right to receive a copy of this notice.
- The right to file a complaint with the Medical Director at Health Brigade, or with the Department of Health and Human Services. We will not retaliate against you for filing a complaint.
Reasons we can share health records without your permission:
- To treat you. For example, if a doctor treating you for an injury needs to know about your overall health.
- To run our organization. For example, to improve your care by monitoring your health information.
- To bill for your services.
- To help with public health and safety issues. For example, for preventing disease in a pandemic, or preventing a serious threat to someone’s safety.
- To do research. All research projects are subject to a special approval process that is designed to protect your information.
- To comply with the law. In response to a court order, subpoena, warrant, summons or similar process.
- To respond to organ and tissue donation requests.
- To work with a medical examiner or funeral director.
- To address workers’ compensation, law enforcement and other government requests.
- To respond to lawsuits and legal actions. If you are involved in a lawsuit, we may disclose medical information about you in response to a court or administrative order, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Our Responsibilities:
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if something happens that may have compromised this privacy and security.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us that we can in writing. If you tell us we can, you can change your mind at any time, and must let us know in writing.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Effective 10/5/2020
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