OFFICE POLICIES AND PROCEDURES
At Gardenia Cove, we strive to provide evidence-based, compassionate, holistic and patient-focused professional mental health services in an inviting and accepting environment which promotes overall psychological wellness. In order to best serve our patients, we follow certain policies and procedures. Please read each section carefully. All patients at our practice must agree to and acknowledge these policies by signing this document.
Patient Rights and Responsibilities
I have a right to privacy and confidentiality. All records and communications will be treated confidentially and in compliance with applicable state and federal laws. These laws may obligate my provider or insurance carrier/managed care company to report suspected abuse or neglect, domestic violence, and those who pose a danger to themselves or others. In these cases, I, the patient, understand that without a Release of Information on file, my care may not be discussed with anyone (family, spouse, other medical providers, etc.) I understand that in order for my insurance or managed care company to pay for services, my provider must submit to the company a diagnosis which describes a psychiatric disorder for which I am receiving treatment. This information is often stored in a medical information data bank that other insurance companies may access when I apply for insurance. I realize that if I do not wish to release this information, I must pay out-of-pocket the full cost of my services at the time they are provided. Additionally, my records may have to be shared if we are served a court-ordered subpoena of documents.
My health is my responsibility. I will use emergency services, as well as my treatment provider, for any and all serious situations that arise, even if after normal office hours. I will work with my provider to achieve my treatment goals and will advise my treatment provider of changes in my condition. I give authorization for Gardenia Cove to access my prescription drug history in order to provide complete and thorough treatment. I understand that I can terminate treatment at any time.
My health information, including health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, related billing activity, and similar types of health-related information, created and received by this office in written, electronic, or spoken word may be used and disclosed for treatment purposes, to coordinate my care, for payment purposes, for health care operations, to coordinate my health plan or insurance coverage, to remind me of my appointments, to suggest treatment alternatives, to offer health related products and services, to advert a serious threat to health or safety, to comply with the law and law enforcement officials, for research purposes were permitted and appropriate, to comply with military or government authorities, for workers' compensation purposes, for lawsuit purposes in response to court or administrative orders, to friends and family per my request and permission, or in cases of incapacity. A full list of patient rights and responsibilities can be found on our website on the Privacy Practices Page.
Prescription Refill Request
It is my responsibility to ensure I have an adequate supply of medications. Prescription refills must be requested three (3) business days before the medication will run out. Prescriptions will not be filled after hours or over the weekend, should I call the on-call provider after-hours requesting a refill, it will result in a fee and still no refill will be given. Refill requests received on Fridays will not be completed until the following week. It is my responsibility to notify the office in a timely manner when refills are necessary and make sure I attend regularly scheduled appointments.
It is important to keep my scheduled appointments to ensure that I receive timely refills. Repeated no-shows or cancellations will result in a denial of refills. All prescriptions require a follow up appointment at least every three months, or more frequently as deemed necessary by the prescribing provider. I understand that attending regularly scheduled appointments is necessary for refills as it is essential that I am evaluated to ensure proper medication management. Should a refill be necessary, a charge for staff time may be incurred. New symptoms or events require an office visit. I understand that I will not be diagnosed or treated over the phone. Medication changes will not be made over the phone, an acute visit is necessary to provide appropriate care. I understand it is my responsibility to know what my health insurance plan will and will not cover. If my insurance company asks me to use a mail-order pharmacy for medications, I will contact the mail-order pharmacy and have them fax over the necessary forms. RefillIs can only be authorized on medications prescribed by providers from our office. We will not refill medications that are not for the primary purposes of mental health treatment.
All requests for medical records must be requested in writing and approved by me except in cases where the law requires them to be released. There will be a charge for records to be faxed, printed, or distributed, especially if not for clinical purposes. Please allow up to 14 days for medical record requests to be processed. As a patient I have certain rights to my medical and related billing records. A full list of patient rights and information about how to request information or file a complaint is documented on the Gardenia Cove website on the Privacy Practices page.
Please call our office with any questions or concerns Monday-Thursday from 8:00am-12:00pm and 1:00pm-4:30pm and Friday from 8:00am-12:00pm. For any urgent matters after hours or on the weekend, please call our office number and you will be connected with an answering service. If after-hour calls are greater than 10 minutes or if non-urgent calls are made to the answering service after-hours, a fee will be charged. This fee is not covered by insurance. Always call 911 or go to the nearest emergency room in the event of an emergency. Please note that you can always call and leave a message that our staff will receive during business hours.
No-Shows, Late Cancellation, and Late Arrivals
In order to provide quality psychiatric services while also maintaining a practice, appropriate scheduling is extremely important. In an effort to ensure that everyone receives the highest quality of care, Gardenia Cove avoids overbooking appointments as much as possible. For this reason, the following policy is in place.
I understand that cancellation of a scheduled appointment should be avoided if possible. If I cannot make my appointment, I must cancel within 24 business hours (weekends and holidays are not included in the 24-hour period), in order to avoid a no-show or late cancellation charge.
I understand that if I no-show for an appointment, or do not notify the office of a cancellation at least 24 business hours in advance, I will be charged the cost of a full visit for physician and therapist appointments.
I understand that if I am late for an appointment, my provider will try to squeeze me into the schedule if possible. There may be a significant wait in this instance. If I am over 5 minutes late to a physician or nurse practitioner appointment and unable to wait or there is no way to squeeze me in, I will be charged the full visit for the missed appointment. If I am over 10 minutes late to a therapy appointment and unable to wait or there is no way to squeeze me in, I will be charged the full visit for the missed appointment.
I understand that my insurance company will not cover these charges. I understand that I will not be allowed to schedule another appointment with my provider until this is paid-in-full.
I understand that after two consecutive no-shows or late cancellations, or three no-shows or late cancellations within a 12-month period, I may be terminated from the practice.
Controlled substances have a high rate of abuse due to their addictive properties. They, just like all medications, should be taken exactly as they are prescribed. I understand that any violation of this policy will result in discontinuation of any and all controlled substance from our practice, now and in the future.
1. The purpose of treatment is to improve the quality of life and functional ability of the individual. Medications will be adjusted as necessary to meet these goals.
2. I will inform the office of any new medications, medical conditions, or adverse effects of my medications.
3. I will inform all healthcare providers of the controlled substances I am taking.
4. I understand that there will be no refills on controlled substances before they are due. If any medications are needed before refills are due, a taper dose may be given to decrease risk of withdrawal if needed for that medication.
5. It is my responsibility to safe guard my prescriptions and medications. They will not be replaced if lost, damaged, or stolen.
6. Controlled substances cannot be refilled over the phone. An appointment is necessary to receive a refill. If an appointment must be cancelled, Gardenia Cove will do their best to accommodate me with another appointment to prevent a lapse in treatment. However, I understand that I will need to call the office if I am nearing the end of my prescription.
7. Each controlled substances should only be actively prescribed by one prescriber.
8. If I am prescribed a controlled substance, I will be asked to have a random drug screen as well as a baseline drug screen as these medications can have severe adverse effects when combined with other substances. Failure to complete drug screen is considered abnormal drug screen.
9. Gardenia Cove participates in PDMP, a statewide tracking system pertaining to all controlled medications.
All co-pays and deductibles are expected at the time of service. If full payment cannot be made at the time of service, a $25 late fee will be added to my account. If I do not pay or set up a payment plan with the practice within 30 days, my credit card on file will be charged. As a courtesy, I will be notified by Gardenia Cove via email or phone that this will take place. If my account remains delinquent, management can determine that the practice will refuse to provide services to me until my balance is paid-in-full. Continued delinquency beyond 90 days will lead to termination from the practice and any past due balance will be sent to collections.
We will file an insurance claim to your carrier, provided that we are given proper filing information. Our agreement is with YOU, not your insurance company. If you are a member of an insurance plan in which we are a provider, your copays and deductibles are required as services are rendered. In the event that my insurance company deems a service to be non-covered, as the patient, I understand that I am personally responsible for the full payment.
I agree to have my credit card on file run for the full amount owed for all telehealth visits including copay, deductible amount, or fee, on the day of my appointment.
Court-Related/ Non-Covered Services
All court related preparation, travel, testimony, and waiting time will be billed directly to me at a rate of $600 per hour for Physician, $450 per hour for Nurse Practitioners, and $350 per hour for Therapists, plus any travel expenses and fees associated with compliance. In these circumstances, there is a records fee of $1 per page for the first 25 pages and $0.50 per page thereafter along with a $5 preparation fee. These fees apply for any and all subpoenas related to me.
Phone calls you request with therapists will be billed to you at a rate of $3.33 per minute with a minimum charge of $50. The charge for completing forms or letters will be a minimum of $25. For forms that require more than 15 minutes to complete, an additional $25 will be added.
Termination of Treatment
I have the right to terminate my care at any time. If I decide to do so, I will notify my provider at least two weeks in advance so that effective planning for continues care could be implemented. I also understand that my provider may also terminate my care at any time. If care is terminated by the provider, emergency services and prescription refills will continue to be available for 30 days so as the patient may find another care provider and lapse in treatment may be prevented. If there are safety concerns which cause termination of care, I understand that there will not be any emergency care provided and termination will be effective immediately.
Reasons for termination of care by Gardenia Cove include:
1. Two consecutive no-shows or late cancellations or three no-shows or late cancellations
2. Failure to follow the mutually agreed upon treatment plan.
3. Threatening or verbally abusing any staff member or other patient in any way.
4. Any illegal activity. This includes, but is not limited to, diverting controlled substances prescribed to you.
5. Violating confidentiality standards.
I understand that if I am transferred out of the practice, I will receive a letter by mail explaining termination of the provider-patient relationship. I will be given a list of the mental health providers in the area and will have the right to coordinate the transfer of care with Gardenia Cove and receive medication refills for one month after receiving notice of termination. It is my responsibility to make sure Gardenia Cove has a current address on file in order to contact me.
Consent For Treatment
Gardenia Cove Mental Health, P.C. is a privately owned and operated psychiatric practice that is fully independent in providing clinical services. Our professional records are separately maintained and no one else can have access to them without your specific, written permission. We are fully responsible for the services we provide. This is a voluntary practice and patients are never obligated to receive services from our providers.
The undersigned patient of responsible party (parent, legal guardian, or conservator) authorizes and consents to services by the providers at Gardenia Cove Mental Health, P.C.These services may include assessments and evaluations, psychotherapy, medication management, the ordering of laboratory tests and diagnostic procedures, and other appropriate alternative therapies.
The undersigned person understands that he/she has the right to:
1. Be informed of and participate in the selection of treatment modalities.
2. Receive a copy of this consent.
3. Withdraw this consent at any time.
By signing, I acknowledge that I have read, understand, and agree with all policies and procedures above. I understand that if I do not understand or have questions about these policies, I may discuss them with my provider. While I expect benefits from this treatment, I fully understand that because of factors beyond our control or other factors, such benefits and particular outcomes cannot be guaranteed.
If at any time the immediate safety of myself, patients, staff or any other person is in question, emergency services will be contacted immediately by the practice.
I know of no reasons I should not undertake services provided and I agree to participate fully and voluntarily. I understand that participation / involvement in treatment is expected; I will work on the goals identified through each appointment or participate as expected and/or discussed. I also understand that a satisfactory outcome of treatment cannot be guaranteed and agree to hold harmless, the provider(s) for any and all outcomes of treatment.
Follow through is expected when referrals are made for any adjunctive treatment that may be deemed important to supplement the current level of service provisions. If I refuse to follow the recommendations of my treating professionals, I acknowledge that my involvement with providers at Gardenia Cove Mental Health, P.C. could be placed at risk and may result in a termination of services.
Telehealth Policies and Procedures
Telehealth, for the purposes of this practice, is Video-Based Online Mental Health(VBOMH) services. VBOMH delivers mental health services when a provider and patient are not in the same physical location using interactive HIPPA and HITECH compliant audio and visual electronic systems. These services may also include electronic prescribing, appointment scheduling, and distribution of patient education materials.
Gardenia Cove Mental Health, P.C. strives to provide safe and quality care to our patients. For this reason we have taken the following steps to assure the care patient receive via electronic video and audio systems is safe and effective.
• Doxy.me and Zoom, the platforms Gardenia Cove uses to deliver Video-Based Online Mental Health (VBOMH), are HIPPA & HITECH compliant.
• All providers have and will remain in compliance with all applicable laws, rules, regulations, and state board requirements pertaining to the delivery of Telehealth.
• All providers will provide Telehealth services in a private secure environment with adequate lighting and reasonably soundproof for patient privacy.
• All providers will ensure that all documents containing protected health information or personal heath information, including prescriptions, are transmitted securely in accordance with all privacy rules including HIPPA.
• Gardenia Cove Mental Health, P.C. has proper protocols in place and have trained staff on protocols and procedures related to technical or other or other types of failure that may disrupt service delivery.
• The staff of Gardenia Cove Mental Health, P.C. are appropriately trained and will comply with proper claims submission procedures including the use of proper code
• All providers have proper insurance coverage for Telehealth services.
You agree to receive (you "opt in" to receiving) SMS text messages from our orginazation related to services that we are providing to you. Message and data rates may apply, and message frequency varries. You may text us to STOP at any time to opt out of receiving SMS text messages from us. You may text HELP at any time to receive help.
Consent to Contact Emergency Services/ Duty to Warn
I understand providers are not rendering emergency services and I have been informs of whom to contact upon an emergency or during weekend and evening hours. I also am giving consent for providers or staff members to contact emergency services for me if they deem that I am in need of such services.
I understand that conversations with providers will almost always be confidential. I further understand that the providers, by law, must report actual or suspected child or elder abuse to the appropriate authorities. In addition, providers have a legal responsibility to protect anyone I threaten with violence, harmful, or dangerous actions (including those to myself) and may break confidentiality.
Technical Difficulties/Urgent Situations
If you experience technical difficulties during a Telehealth session call the office to address the issue and reschedule if necessary. The office can be reached Monday-Thursday from 8:00am-12:00pm and 1:00pm-4:30pm and Fridays from 8:00am-12:00pm.
While Telehealth is a wonderful service that can make healthcare more accessible and convenient, it is not the same as a face-to-face visit and may not be for everyone. By consenting to treatment through Telehealth sessions you accept the limitations of this
I as the patient agree to the patient responsibilities listed below. I also understand that my provider may require in-person sessions based on clinical need or if appointments are unable to be consistently completed due to technical difficulties on my end.
• I will be in the state of Alabama at the time services are rendered.
• I will not record any Telehealth sessions.
• I will inform my provider if any other person can hear or see any part of our session before the session begins.
• I understand that an internet connection and compatible device is required for Telehealth sessions. It is my responsibility to ensure the proper functioning of all electronic equipment before my session begins. My provider is not responsible for providing internet connection or equipment, nor are they responsible should the session be interrupted by technical difficulties out of their control.
• I understand that courses of controlled substances cannot be started at Telehealth
• I am financially responsible for services rendered. If my insurance company does not cover Telehealth treatment, I may be charged the full visit fee for my appointment.
• No Show/Late Cancellation fees still apply for Telehealth visits.
• If I choose to pay for services out of pocket and not run visit fees through my insurance provider I recognize that any amount paid will not go towards meeting my deductible.
By signing I, the patient, am consenting to receive Telehealth treatment and agree to follow these policies and procedures.
Consent to Charge Card
I hereby authorize Gardenia Cove Mental Health to charge the credit or debit card on file in my patient account for all fees owed on my account related to professional services.
Fees will only be charged for: Any Balance Deemed Patient Responsibility by Insurance Including Copays and Deductible Amounts Due, No Show and Late Cancellation Fees, Form Completion, Letter Preparation, Returned Checks, and Transaction Fees Due to Insufficient Funds.
HIPAA DATA USAGE AGREEMENT
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.
1. Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician's practice.
Following are examples of the types of uses and disclosures of your protected health information that your physician's office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.
Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities.
We will share your protected health information with third party "business associates" that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object.
We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:
Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.
Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice's premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
Workers' Compensation: We may disclose your protected health information as authorized to comply with workers' compensation laws and other similar legally-established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization: Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization.
Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object: We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest.
Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi.
Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
2. Your Rights
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records.
Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.
You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.
You may contact your doctor if you have any other questions about privacy practices.
With my signature below I acknowledge that I have read and agree to the policies and procedures in this document.