This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Please review carefully.
This Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or oral, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse and disclose your health information.
As required by HIPAA, we have prepared this statement of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.
We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations.
Treatment means providing, coordinating, or managing health care related services by one or more health care providers. An example of this would include a physical examination.
Payment means such activities, as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to our insurance carrier for payment.
Health care operations include business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.
We may also create and distribute de-identified health information by removing all references to individually identifiable information.
We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken action relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer.
The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are however, not required to agree to a requested restriction if we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or alternative locations.
The right to inspect and copy your protected health information.
The right to amend your protected health information.
The right to receive an accounting of disclosures of protected disclosures of protected health information. The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.
This notice is effective as of December 12, 2006, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reservice the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post, and you may request a written copy of a review Notice of Policy Practices from this office.
You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal written complaint with our office or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provision of this notice or the policies and procedure of our office. We will not retaliate against you for filing a complaint.
Please contact us for more information about HIPAA or to file a complaint, by asking to speak to our Privacy Officer or for written inquires, note “Attention Privacy Officer.”
The U.S. Department of Health & Human Services
Office of Civil Rights 200 Independence Avenue
SW Washington, DC 20201
PH (202) 619-0257 or toll free: 1-877-696-6775
Acknowledgement of Receipt of Notice of Privacy Practices
Respect for our patients’ privacy is of utmost importance to us. As required by law, we will protect the privacy of health information that may reveal your identity and provide you with a copy of our Notice of Privacy Practices that describes the health information privacy practices. Our medical staff and affiliated health care providers value your privacy as much as your well-being.
Our Notice will be posted on our website and in any other locations where we provide services. You will also be able to obtain your own copy of the Notice by accessing the patient portal or our website at www.mwcofga.com , or asking for one at the time of your next visit.
By signing below, I acknowledge that I have been provided a copy of this Notice and have therefore been notified of how health information about me, may be used and disclosed, and how I may obtain access to and control this information.
Finally, by signing below, I consent to the use and/or disclosure of my health information as described in this Notice, including treatment, to seek and receive payment for services given me, and for the business operations of the practice and its staff.
If you have any questions about this Notice or would like further information, please contact the Privacy Officer at 877-755-2212
I understand that my medical records may be used to carry out treatment, payment, or health care operations. I authorize Medical Wellness Center of Georgia to release medical or other information about this care to other referring physicians, my personal physician, discharge planner, Medicare, Medicaid, and all other health insurance companies to complete patient claims as well as appropriate government agencies of the U.S. as may be required by Federal Law.
I hereby voluntarily consent to care, treatment, testing, and all other services performed by healthcare providers at Medical Wellness Center of Georgia. I understand that I may revoke this consent at any time via written, dated, and signed communication letter provided to this office.
Medication history transactions - Provides the health care provider with information about your current and past prescriptions. This allows health care providers to be better informed about potential medication issues to improve safety and quality. This data can indicate compliance with prescribed regimens; therapeutic interventions; drug-drug and drug-allergy interactions; adverse drug reactions; and duplicative therapy. The history would include medications prescribed by your health care provider at Medical Wellness Center of Georgia, as well as other health care providers involved in your care and may include sensitive information including, but not limited to, medications related to mental health conditions, venereal diseases/sexually transmitted diseases, substance (drug and alcohol) abuse, genetic and other diseases. As part of this Consent Form, you specifically consent to the release of this and other sensitive health information.
For Office Use Only: If the patient does not sign this acknowledgement form, record here the good faith efforts made to obtain this acknowledgement and consent.