Through a series of interlocking regulatory rules, HIPAA compliance is a living culture that health care organizations must implement into their business in order to protect the privacy, security, and integrity of protected health information.
PATIENT INFORMATION 1
--- RESPONSIBLE PARTY ---
--- EMERGENCY CONTACT ---
KAUSTUBH V. PATANKAR, MD, FACC | MIMI SEN BISWAS, MD, MHSC | NADER N. ATTIA, DO | NIRAJ V. PAREKH, MD | JEREMY, COX, DO | JATIN N. AMIN, MD | BRADLEY S. MESSENGER, MD | SANDEEP SANGODKAR, DO. FACC | SINAN SARSAM MD | CHRISTOPHER SEAMAN, MD |
Authorization to obtain medical records:
I hereby authorize Cardiology Specialists Medical Group to obtain any and all medical records concerning my care from any physician, hospital, or other healthcare professionals that have or will provide me with medical care.
Authorization to release medical records:
I also authorize Cardiology Specialists Medical Group to release any and all medical records concerning my care to any physician, hospital, or other healthcare professionals that have or will provide me with medical care.
Additionally, I authorize Cardiology Specialists Medical Group to release any and all medical records concerning my care to Medicare, Medicaid, other health insurance companies, third party administrator, or managed care companies.
Patient RightsFollowing is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. 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, or administrative action or proceeding, and protected health information that is subject to law that prohibits access toprotected health information.
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 purpose of treatment, payment, or healthcare 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, for notification purposes, as described in this notice of privacy practices. You must state the specific restriction requested and to whom you want the restrictions to apply towards.
Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your health information will not be restricted.You then have the right to use another healthcare professional.
You have the right to request to receive confidential communications from Cardiology Specialist by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you agreed to accept this notice alternatively, i.e.electronically.
You may have the right to have your physician amend your protected health information. 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.
You have the right to receive an accounting of certain disclosures Cardiology Specialisthave made, if any, of your protected health information:
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
ComplaintsYou may complain to CardiologySpecialistorto the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with us by notifying our privacy contact. We will not retaliate against you for filing a complaint.
This notice was published and becomes effective on/or before April 14, 2003.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone a tour main number.
Signature below is the only acknowledgment that you have received this notice of our privacy practices:
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 ofPrivacyPracticesdescribeshow we may use and disclose yourprotected health information to carry out treatment, payment or health care operationsandforotherpurpose that are permitted orrequirebylaw.It also describes your rights to access and controls 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.
Uses and Disclosures of Protected Health InformationYourprotected healthinformationmaybe used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you,to pay any health care bills, to support the operation of the physician's practice, and any other use required by law.
TreatmentWe will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care for you. Your protected health information may be provided to a physician to whom you've been referred to, to ensure that the physician has the necessary information to diagnose or treat you in regards to the continuity of your care.
PaymentYour protected health information will be used, as needed, to obtain payment for your health care services.For example, obtaining approval for the hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Health OperationsWe 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 reviewactivities, training of medical students, licensing, and conducting or arranging for other business activities. In addition, we may use a sign-in sheet at the front desk where you will be asked to sign your name and indicate your physician you are to be seeing. We may also call you by name in the waiting room when you are ready to be seen by the physician.
We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law: public health issues, communicable diseases, health oversight, abuse or neglect, FDA requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity, national security, Workers’Compensation, and inmates. Required u uses and Disclosures: Under the law, we must make disclosures to you and when requirements of section 164.500.
Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law.You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
I request that my payment of authorized health plan benefits be made on my behalf to Cardiology Specialists Medical Group, inc. for any services provided by that physician/supplier/ facility. I authorize any holder of medical information about me to release to the HCFA (Health Care Finance Administration), and its agents any information needed to determine these benefits payable to related services.
I Understand my signature requests that payments be made and authorizes the release of medical information necessary to pay any claim. If other health insurance is indicated in item 9 of the HCFA 1500 form or elsewhere on the approved claim form, or electronically, submitted claims. My signature authorizes the release of information to the insurer or agency above.