• RACHEL'S HELPING HANDS CANCER GRANT

    HIPAA Authorization
  • SUMMARY

    WHAT IS THE NOTICE FOR? This notice of Privacy Practices (Notice) describes how Rachel's Helping Hands Cancer Foundation (We or US) may use and disclose your medical information that we maintain and how you can get access to this information. 

    WHO ARE WE?  RACHEL'S HELPING HANDS CANCER FOUNDATION is a non-
    profit organization which provides monies for cancer patients who cannot afford their
    deductibles.

    WHY DO YOU NEED THIS NOTICE? The Health Insurance Portability and Accountability Act of 1996.  as amended by the Health Information Technology for Economic and Clinical Health Act, places certain obligations upon us with regard to how we may use and disclose your personal health information (PHI). Your PHI includes medical information about you such as your medical records and the care and services that you have received. We are committed to maintaining the privacy of your PHI. When we need to use or disclose it, we will comply with the full terms of this Notice. Anytime we are permitted to or required to share your PHI with others, we only provide the minimum amount of data necessary to respond to the need or request unless otherwise permitted by law.

    WHEN CAN WE USE/DISCLOSE YOUR PHI? There are certain uses and disclosures of your PHI that we may undertake without your written or other authorization. These uses and disclosures may be for purposes such as to provide you with treatment, obtain payment for services we have provided, and other health care operations (such as administration, quality improvement, cost studies and other activities designed to improve the service we provide to all our patients). Some other examples include: PHI made known to your relatives, close friends, or caregivers, public health activities and officials, reporting of abuse or neglect as may be required by law, health oversight activities, judicial and administrative proceedings, law enforcement officials, workers' compensation, and other individuals and activities as set forth in this Notice. Individuals who may have access to your information without your written or other authorization may include doctors, nurses, health care students, and other hospital staff.

    WE MUST OBTAIN YOUR WRITTEN AUTHORIZATION FOR ANY USE OR DISCLOSURE NOT SET FORTH IN THIS NOTICE.   You may revoke this authorization at any time. In addition to obtaining your written authorization for uses or disclosures not described in this Notice, we generally will also need to seek your written authorization or approval prior to disclosing the following information:

    • HIV/AIDS related information
    • Sexually transmitted disease information
    • Psychotherapy notes
    • Mental health information Drug and alcohol information Genetic information
    • Any information where you, if a minor, sought emancipated treatment (e.g., care related to your pregnancy or child, sexually transmitted diseases, etc.)

    We will also seek your written authorization for any "marketing" activities we may conduct or where we would receive money for providing a third party with your PHI.

    WHAT RIGHTS DO YOU HAVE FOR YOUR PHI? You have the right to ask us to limit certain uses and disclosures of your PHI. We will consider ALL request but may not be required to agree to your requested limitations. You also have the right to inspect and receive copies of your PHI, the right to request a change or amendment be made to your PHI, the right to an
    accounting (a list) of certain disclosures of your PHI, and the right to revoke any authorization you may have made to the extent we have not yet relied upon it. You also have the right to receive a paper copy of this Notice at any time.

    CAN WE CHANGE THIS NOTICE? We may change this Notice at any time. The revised Notice will apply to all PHI that we maintain. However, if we do change this Notice, we will only make changes to the extent permitted by law. We will also make the revised notice available to you by posting it in a place where all individuals seeking services from us will be able to read the Notice. You may obtain the new Notice in hard copy as well from our Privacy office.

    ADDITIONAL INFORMATION/COMPLAINTS. You may contact our Privacy Office if you wish any additional information or have questions concerning this Notice or your PHI. If you feel that your privacy rights have been violated, you may also contact our Privacy Office and file a written complaint with the Office of Civil Rights of the U.S. Department of Health and Human Services. We will NOT retaliate against you if you file a complaint with us or the Office of Civil Rights.

    THE ABOVE IS ONLY A SUMMARY OF THE RIGHTS AND OBLIGATIONS WITHIN THIS NOTICE. PLEASE READ CAREFULLY THE ENTIRE NOTICE THAT
    FOLLOWS. WE WELCOME ANY QUESTIONS YOU MAY HAVE.

  • I,   *   *  , (name of patient) hereby authorize   *   *   (name of Healthcare Provider/Facility/Physician) to release & furnish to Rachel's Helping Hands Cancer Foundation copies of full & complete protected medical information.

  •  -  -
    Pick a Date
  • RACHEL'S HELPING HANDS CANCER GRANT

    HIPAA Authorization - Patient
  • SUMMARY

    WHAT IS THE NOTICE FOR? This notice of Privacy Practices (Notice) describes how Rachel's Helping Hands Cancer Foundation (We or US) may use and disclose your medical information that we maintain and how you can get access to this information. 

    WHO ARE WE?  RACHEL'S HELPING HANDS CANCER FOUNDATION is a non-
    profit organization which provides monies for cancer patients who cannot afford their
    deductibles.

    WHY DO YOU NEED THIS NOTICE? The Health Insurance Portability and Accountability Act of 1996.  as amended by the Health Information Technology for Economic and Clinical Health Act, places certain obligations upon us with regard to how we may use and disclose your personal health information (PHI). Your PHI includes medical information about you such as your medical records and the care and services that you have received. We are committed to maintaining the privacy of your PHI. When we need to use or disclose it, we will comply with the full terms of this Notice. Anytime we are permitted to or required to share your PHI with others, we only provide the minimum amount of data necessary to respond to the need or request unless otherwise permitted by law.

    WHEN CAN WE USE/DISCLOSE YOUR PHI? There are certain uses and disclosures of your PHI that we may undertake without your written or other authorization. These uses and disclosures may be for purposes such as to provide you with treatment, obtain payment for services we have provided, and other health care operations (such as administration, quality improvement, cost studies and other activities designed to improve the service we provide to all our patients). Some other examples include: PHI made known to your relatives, close friends, or caregivers, public health activities and officials, reporting of abuse or neglect as may be required by law, health oversight activities, judicial and administrative proceedings, law enforcement officials, workers' compensation, and other individuals and activities as set forth in this Notice. Individuals who may have access to your information without your written or other authorization may include doctors, nurses, health care students, and other hospital staff.

    WE MUST OBTAIN YOUR WRITTEN AUTHORIZATION FOR ANY USE OR DISCLOSURE NOT SET FORTH IN THIS NOTICE.   You may revoke this authorization at any time. In addition to obtaining your written authorization for uses or disclosures not described in this Notice, we generally will also need to seek your written authorization or approval prior to disclosing the following information:

    • HIV/AIDS related information
    • Sexually transmitted disease information
    • Psychotherapy notes
    • Mental health information Drug and alcohol information Genetic information
    • Any information where you, if a minor, sought emancipated treatment (e.g., care related to your pregnancy or child, sexually transmitted diseases, etc.)

    We will also seek your written authorization for any "marketing" activities we may conduct or where we would receive money for providing a third party with your PHI.

    WHAT RIGHTS DO YOU HAVE FOR YOUR PHI? You have the right to ask us to limit certain uses and disclosures of your PHI. We will consider ALL request but may not be required to agree to your requested limitations. You also have the right to inspect and receive copies of your PHI, the right to request a change or amendment be made to your PHI, the right to an
    accounting (a list) of certain disclosures of your PHI, and the right to revoke any authorization you may have made to the extent we have not yet relied upon it. You also have the right to receive a paper copy of this Notice at any time.

    CAN WE CHANGE THIS NOTICE? We may change this Notice at any time. The revised Notice will apply to all PHI that we maintain. However, if we do change this Notice, we will only make changes to the extent permitted by law. We will also make the revised notice available to you by posting it in a place where all individuals seeking services from us will be able to read the Notice. You may obtain the new Notice in hard copy as well from our Privacy office.

    ADDITIONAL INFORMATION/COMPLAINTS. You may contact our Privacy Office if you wish any additional information or have questions concerning this Notice or your PHI. If you feel that your privacy rights have been violated, you may also contact our Privacy Office and file a written complaint with the Office of Civil Rights of the U.S. Department of Health and Human Services. We will NOT retaliate against you if you file a complaint with us or the Office of Civil Rights.

  • I,   *   *    (name of patient) understand & abide by all facility policies in regards to HIPAA & The Summary of Rights & Obligations within this notice.

  • Clear
  •  -  -
    Pick a Date
  • Confidential Communication List

  • I,     (patient name),  give my permission for the following person/persons to inquire and receive medical updates regarding my protected health information and billing information.


  •  
  • Clear
  •  -  -
    Pick a Date
  • Personal Story

    Authorization Form
  • I,         ,  (patient) understand that (i) certain information about me, including but not limited to my age, diagnosis and a description of the effect that my diagnosis has had on me and my family (my “Personal Story”), will be shared with Rachel’s Helping Hands (“RACHEL’S HELPING HANDS CANCER FOUNDATION”) in connection with the RACHEL’S HELPING HANDS CANCER FOUNDATION GRANT APPLICATION, (ii) if I am awarded a grant under the RACHEL’S HELPING HANDS CANCER FOUNDATION GRANT (the “Grant Program”), RACHEL’S HELPING HANDS CANCER FOUNDATION may wish to share my Personal Story or any part thereof (a) with the donor who supported the grant made to me, and/or (b) on RACHEL’S HELPING HANDS CANCER FOUNDATION’s website and social media websites and applications, including Twitter, Facebook and Instagram (“Online Uses”), (iii) my Personal Story will not be shared with any third party unless I select one of the options listed below and (iv) my eligibility for a grant under the Grant Program will not be affected by my decision to select or not select any of the options listed below.

  • Clear
  •  -  -
    Pick a Date
  •  
  • Should be Empty: