Acknowledgement of Receipt of Notice Brainchild Institute 4340 Sherida - PDF document

Acknowledgement of Receipt of Notice Brainchild Institute 4340 Sheridan Street #202 Hollywood, Florida 33021 (954) 987-8887 I, _____________________, hereby acknowledge that I have received a copy of Brainchild Institute’s Notice of Privacy Practices in regard to the patient, ___________________________________ Patient’s Name ___________________________________ _________________________ Signature of patient or Date responsible party If not signed by the patient, please indicate relationship:___________________ Brainchild Institute 2 PRIVACY NOTICE THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. Your protected health information may be used or disclosed only for these purposes unless Brainchild Institute has obtained your authorization or the use or disclosure is otherwise permitted by the HIPAA Privacy Regulations or State law. Treatment: Brainchild Institute may disclose your protected health information to provide, coordinate, or manage your health care and any related services. We may use or disclose your health information to obtain payment for services provided to you. The staff involved in your care will document in your record results of your assessment or the plan of treatment established for you. We may also disclose protected health information to other physicians who may be treating you or consulting with your physician with respect to your care.We will provide future physicians or subsequent healthcare providers with copies of various reports that should assist him or her in treating you. We may also use health information about you to call you or send you a letter to remind you about an appointment, to follow up with test results, or to provide you with information about other treatment and care that could benefit you. Payment: We may use or disclose your health information to obtain reimbursement for services provided to you. A bill will be sent to your third party payor (insurance). The information on or accompanying the bill may include information that identifies you, as well as your diagnoses, procedures, healthcare providers and supplies used. We may also contact your insurance company to determine if they will pay for your diagnostic or treatment as part of their certification process. Healthcare Operations: We may disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing practitioner performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to use of your healthcare information in connection with our healthcare operations, you may give us written authorization to use your health information or disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.Other Disclosures: We must disclose your health information to you, as described in the patient’s rights section of this Notice. We may disclose to a family member, or other relative, close personal friend or any other person you identify, health information directly relevant to that person’s involvement in your care or payment related to your care. The disclosure will only be done if you agree and do not express an objection when given the opportunity. If you do not object to these disclosures or we can infer from the circumstances that you do not object or we determine, in the exercise of our professional judgment, that it is in your best interests for us to make disclosure of information that is directly relevant to the person’s involvement with your care, we may disclose your protected health information as described. Required by Law: We may also disclose health information without your consent or authorization as required by law to the following entities or types of entities that include, but not limited to: Food and Drug Administration Public Health or legal authorities charged with disease prevention Correctional institutions Workers Compensation agents Organ and Tissue Donation Organizations Military Command Authorities Health Oversight Agencies Funeral Directors, Coroners and Medical Examiners 3 National Security and Intelligence Agencies Protective services for the president and others Law enforcement as required by law or in accordance with a valid subpoena We will obtain written permission from you prior to using information in your records for marketing purposes. PATIENT RIGHTS You have the right to: Inspect and obtain a copy of your health record. There may be a charge to cover the cost of copying your recordRequest an amendment of your health records Obtain an accounting of non-authorized disclosures of your protected health information (these are mandated reporting laws such as child abuse). Request communication of your health information in a certain way or at a certain location. For example, you can ask that we contact you by mail and not by telephone, or that we contact you at a specific telephone number, or that we use alternative address for billing purposes, or that we not leave a message on certain answering machines. Revoke authorization to use or disclose health information except to the extent that action has already been takenThe right to request restrictions on certain uses and disclosures of your protected health information which we may not agree to but if we do, such restrictions shall not apply unless our agreement is changed in writing OUR DUTIES We are required by law to maintain privacy of your protected health information: Provide you with a notice as to our legal duties and privacy practices with respect to information we collect about you through this Notice; Abide by the terms of this notice currently in effect Notify you if we are unable to agree to a requested restriction Follow reasonable requests you make to communicate with you as you instruct – for example, contact you at a certain telephone number or address Provide you a paper copy of this notice of privacy practices upon request EFFECTIVE DATE This Notice is effective December 1st, 2009. HIPAA Notice of Privacy Practices – Contact Person Contact Person Information regarding matters covered by this Notice can be requested by contacting the Privacy Contact in writing. Complaints against Brainchild Institute can be mailed to the Privacy Contact by sending it to: Privacy Contact Leah Light, Au.D Brainchild Institute 4340 Sheridan St. #202 Hollywood, FL 33021 Telephone: (954)987-8887