HIPAA
A federal law known as HIPAA (the Health Insurance Portability and Accountability Act) requires that medical practices and other medical providers explain to you the rules governing the privacy of your medical records. We comply with HIPAA and all local/state health privacy regulations. If you would like a copy of our official HIPAA policy it is available at the front desk or our website (poolesvillefamilypractice.com ).
Poolesville Family Practice is only contracted with Medicare (and no other private insurer)
I understand that Poolesville Family Practice is not contracted with my insurance company (except Medicare). Poolesville Family Practice will submit the bill for your vaccine administration to your insurance, but you are NOT responsible for any out of pocket expenses. If you do not have insurance, we are offering the vaccine without any charges to you.
Prescription History Access:
In order to better care for you, our doctors and staff may need to access your prescription medication history. By signing this document you give us permission to have access to your electronic prescription history.
Maryland Health Information Exchange:
We have chosen to participate in the Chesapeake Regional Information System for our Patients, Inc. (CRISP), a statewide health information exchange. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “opt-out” and prevent access of your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at www.crisphealth.org.
Immunet:
As required by the State of Maryland, we will submit your vaccine records from our office to Immunet. ImmuNet is Maryland’s Immunization Information System (IIS), a confidential and secure database that is HIPAA compliant. It stores an individual’s vaccination records, and is a web-based tool for healthcare providers and schools to keep their patients/students vaccinated on time and avoid under or over vaccination.
I agree to all of the above statements and have had all of my questions regarding the above statements answered to my satisfaction.