INDIVIDUALIZED MEDICINE, LLC PATIENT INFORMATION FORM

Transcription

1 INDIVIDUALIZED MEDICINE, LLC PATIENT INFORMATION FORM DATE NAME SSN ADDRESS CITY STATE ZIP PHONE CELL DOB AGE SEX M F IN CASE OF EMERGENCY CALL PHONE PATIENT EMPLOYED BY OCCUPATION BUSINESS PHONE BUSINESS ADDRESS PERSON RESPONSIBLE FOR ACCOUNT RELATION TO PATIENT DOB SSN ADDRESS (IF DIFFERENT FROM PATIENT) EMPLOYED BY BUSINESS ADDRESS BUSINESS PHONE INSURANCE COMPANY SUBSCRIBER ID OCCUPATION CELL GROUP ID IS PATIENT COVERED BY OTHER INSURANCE PLAN? YES NO SUBSCRIBER NAME DOB _RELATION TO PATIENT ADDRESS HOME PHONE BUSINESS PHONE CELL SUBSCRIBER EMPLOYED BY ADDRESS INSURANCE COMPANY SUBSCRIBER ID# GROUP# _SSN I, THE UNDERSIGNED CERTIFY THAT I AND MY DEPENDENTS HAVE INSURANCE COVERAGE WITH THE COMPANY LISTED ABOVE AND ASSIGN TO INDIVIDUALIZED MEDICINE, LLC ALL INSURANCE BENEFITS. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE. I HEREBY AUTHORIZE INDIVDUALIZED MEDICINE, LLC TO RELEASE ALL INFORMATION NECESSARY TO SECURE THE PAYMENT OF BENEFITS; I AUTHORIZE THE USE OF THIS SIGNATURE ON ALL INSURANCE SUBMISSIONS. SIGNATURE DATE

2 INDIVIDUALIZED MEDICINE, LLC HEALTH HISTORY FORM PATIENT S NAME: DOB: DATE ALLERGIES: SURGERIES: HOSPITAL ADMISSIONS: CURRENT HEALTH PROBLEMS: PREVIOUS HEALTH PROBLEMS: FAMILY HISTORY CANCER DIABETES HEART DISEASE HIGH CHOLESTEROL SOCIAL HISTORY MARITAL STATUS SMOKING DRUGS EMPLOYMENT ALCOHOL OCCUPATIONAL EXPOSURE

3 INDIVIDUALIZED MEDICINE, LLC CONSENT FOR TREATMENT This document is a binding contract setting forth the obligations I assume in consideration for the medical care and treatment to be provided to me. I as the patient agree to be bound by its terms. FREE WILL: I am here of my own free will, representing no official agency or other organization, voluntarily requesting services for me and/or my dependents. I understand that all requests for information by official agencies or other organizations must be done in writing. NOTICE IS HEREBY GIVEN THAT PERMISSION IS NOT GRANTED TO INDIVIDUALS WORKING IN AN OFFICIAL (E.G. GOVERNMENT) CAPACITY SEEKING INFORMATION WITHOUT THE WRITTEN CONSENT OF THE LEGAL COUNSEL REPRESENTING THE HEALTHCARE PROVIDERS AT INDIVIDUALIZED MEDICINE LLC. INTRODUCTION: I have specifically sought out the services and perspective of the providers of Individualized Medicine LLC for their Integrative approach to medicine, drawing on Traditional and Complementary/Alternative Medicine methods. I have sought out my provider because I know that he/she is knowledgeable in both conventional and unconventional methods of treating illnesses and draws upon this experience and expertise to individualize and customize a treatment plan for each patient depending on the presentation. I understand that I will be presented with treatment options that include traditional and alternative approaches, and that ultimately, I will make the final decision on which method of treatment is right for me and my family. RIGHT OF CHOICE: I have been fully informed that there are different schools of medical theory and that medicine is an evolving science. I am aware that in this evolving science, doctors sometimes differ on their approaches to diagnosis or treatment of illness or problems. I have had the opportunity to consider different approaches or schools of medical thought and ask questions of my provider. I understand that I have the right to accept or refuse medical care, based upon my personal judgment. Complementary and Alternative Medicine, like any other treatment or medication, may or may not alleviate or cure the condition(s) for which it is offered. Likewise, I acknowledge that in any medical procedure or treatment that there are certain complications reported in medical journals and/or studies that are due to the procedure or treatment and unexpected adverse effects that may result. As part of the consideration I am giving to my provider in turn for treating me, I make a binding promise to notify the provider if I believe that I am suffering from any unexpected adverse effect. If I fail to notify my provider within a reasonable time of the onset of such unexpected adverse effect, I agree that any claim that I may have resulting from such adverse effect will be barred, waived and released. I further make a binding promise to notify the provider if I believe that I am suffering from any complication. It is important that you read and understand the information contained in this form so that you can make an informed choice about being treated at Individualized Medicine LLC, by its

4 agents, and your provider, specifically. If after reading this form, you have any concerns or questions regarding the care you will receive, you should talk to your provider. AUTHORIZATION: I have read the above or it has been explained to me. I acknowledge that I have been given the opportunity to ask my provider about any treatments which I am consenting to receive now and in the future including alternative forms of treatment, testing and the risks of such treatment, with the understanding that the ultimate decision lies with me regarding which treatment approach I desire. Testing and/or treatments that may be offered or recommended by your provider at Individualized Medicine LLC may include radiographic imaging, laboratory studies, dietary changes, and referrals to other providers. I acknowledge that the specific risks and complications of any treatment program requested will be discussed fully with my provider and I will have the opportunity to ask questions. I understand this is a general consent form to treat, accepting that the providers at Individualized Medicine LLC use alternative and traditional approaches to medicine. I realize that I may leave Individualized Medicine LLC at any time. In doing so, I may be requested to sign a form acknowledging this decision. However, if I decide to revoke my consent to treatment, the consent shall remain applicable for any treatment and procedures rendered prior to any such revocation. It was my independent choice whether to see a provider at Individualized Medicine LLC and it is always my choice whether to continue medical care with Individualized Medicine LLC. I also understand that the providers of Individualized Medicine LLC reserves the right, at any time and without cause, to discontinue any patient due to poor compliance with the recommended program or treatment plan for any other reason. I have read this form that serves as an informed consent document and an authorization and have been given the opportunity to ask questions. If I have questions later, I understand I can contact a provider at Individualized Medicine LLC. I will be given a signed copy of this document for my records. The risks and benefits to me have been explained and I am encouraged to and will have the chance to ask questions and these questions will be answered. BY COMPLETING AND SUBMITTING THIS FORM, I AGREE THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE INFORMATION, THE ELEMENTS OF MY INFORMED CONSENT, MY RIGHTS AND RESPONSIBILITIES, AND HEREBY GIVE CONSENT TO UNDERGO TREATMENT AT INDIVIDUALIZED MEDICINE LLC. INFORMATION ABOUT ME AND MY RECORDS WILL BE CONFIDENTIAL. DATA WILL BE STORED SECURELY AND WILL BE MADE AVAILABLE ONLY TO THE PERSONS PARTICIPATING IN MY EVALUATION AND SUBSEQUENT TREATMENT, IF ANY, UNLESS I SPECIFICALLY GIVE PERMISSION IN WRITING UNLESS OTHERWISE REQUIRED BY LAW. SIGNATURE PRINTED NAME DATE

5 INDIVIDUALIZED MEDICINE, LLC CONSENT TO SHARE INFORMATION Persons who are involved in your care (family, friends, other doctors, etc.) may inquire about your treatment, lab results, prescriptions, etc. Please let us know what persons we may share information with. (Please note: In emergency situations or other situations outlined in our Notice of Privacy Practice we may share information with others who are not specifically listed on this form.) Please list those persons & contact information (including family members, friends, previous physicians, current physicians, and any other doctors/specialists) with whom we may share your information: What is the best phone number for us to contact you? Phone Number: What is this number (Home, Work, Cell, Other)? From time to time we will leave a message for you (as stated in our Notice of Privacy Practices) on an answering machine, voice mail, or with another individual in your absence. Is it OK for such message to include details (such as diagnosis and medication information) at this number? What other ways may we contact you? Please list all that are acceptable ways to reach you. Home Phone Number: Is it OK to leave a detailed message at this number in your absence? Work Number: Is it OK to leave a detailed message at this number in your absence Cell Phone Number: Is it OK to leave a detailed message at this number in your absence? Other: Is it OK to leave a detailed message at this number in your absence? Signature of Patient or Legal Representative Date Date of Birth Print Name of Patient or Legal Representative SSN Relationship to Patient

6 INDIVIDUALIZED MEDICINE, LLC OFFICE & FINANCIAL POLICIES We would like to thank you for choosing Individualized Medicine, LLC as your medical provider. We have written this policy to keep you informed of our office policies. Office Hours: Our regular office hours are Monday - Friday, 9:00 a.m. 5:00 p.m. Appointments: We see patients by appointment only. Same day appointments are usually available for urgent or sudden illness. Urgent Need or Sudden Illness: We have a limited number of same day or work-in appointments available every day. Please call early in the day, as these spots fill up quickly. Cancellations: Please call within 24 hours if you are unable to keep your scheduled appointment. This allows us to provide that time slot to another patient. Running on time: We know your schedule is busy and that your time is valuable. Please let us know if you have waited more than 15 minutes so we can double check to see if you have been properly checked in. Emergencies: For a serious emergency call 911 right away. If you are not sure and you call our office, please be sure to tell the person who answers the phone that it is an emergency. After Hours: After hours you will reach our answering machine. If the problem can be addressed the next day, please leave us a message and we will call you in the morning as soon as possible. If you need to see a doctor after hours please report to emergency room. Patient Portal: Provision of your address to our front office staff constitutes consent for us to contact you by to enroll you into Patient Fusion, our patient portal. This portal will streamline your access to your PHI including vitals, medication lists, and lab results. Treatment of Minors: Dr. Malykh accepts patients 18 years of age and older. Lab Work: Some lab work we do in our office-like glucose tests, urinalysis, protimes, hemoglobin A1C s. These tests are drawn by one of the medical assistants. Other tests will be sent out to a reference lab. Complete Physical Exams: We believe that routine, annual complete physical exams with screening lab tests are very important to the maintenance of good health. However, insurance benefits vary. Some policies cover wellness and others cover visits when you have a complaint. Please learn about your benefits prior to your appointment so you will know what is covered by your insurance plan. Nursing Staff: We often refer to staff that assist our providers as nurses although most of them are not technically nurses because they are not licensed by the state as an LPN or RN. Most are Medical Assistants. This means they have technical school or on-the-job training in providing medical assistance to the physicians. They take blood pressures, weigh you, ask about your symptoms, give injections, schedule tests and call in prescriptions. They work under the direct supervision of the doctor. Speaking with a Nurse : When you call the office, you can request to speak with a nurse, however many times the nurse may be engaged with other duties at the time of your call. When the voic attendant answers, please leave a detailed message-including your full name, DOB, and contact number. Calls are usually returned within one business day. (CONTINUED ON NEXT PAGE)

7 Test Results: We call our patients with abnormal test results. Please make sure to provide us with you latest address and phone number. Try to do your tests ordered 5-7 days before your next appointment. Prescriptions and Refills: The best time to get a prescription refill is at your appointment. If you need to call for refills, don t wait until you have run out. Most refills require the doctor s approval. Don t go to the pharmacy to wait for your prescription to be called in. Call them first to see if it is ready. Some medications have potential side effects that must be monitored. We require check-ups every 3 or 4 months for these medications. Be sure to keep those follow-up appointments. Some prescriptions cannot be called in. The prescription must be printed for you to pick up. Don t call after hours for prescription refills. There is no access to your chart and we may not be able to help you. Provide 72 hours advance notice for prescription refills. Bring a complete list of all current medications with dosages and instructions to each office visit for your doctor to review. Notify us of recent visits to other doctors/hospitals and any new allergies to medications since your last visit. Samples: We sometimes offer you samples to help you try out a new medication before you purchase it. Remember that samples are not a long term way to fill your prescription. We do not always have samples of your medications. Please do not rely on samples for medications you take long term. Narcotics: We do not prescribe narcotics for chronic use. We do not call in narcotics after hours. If you require use of narcotics, our physicians will refer you to a pain management specialist. Mail Order Prescriptions: Many insurance plans offer financial incentives for using mail order pharmacies. We are glad to print out prescriptions for your mail order pharmacy needs. You can pick these up at our office. We do not fax or call in mail orders. Referrals: Referrals are handled by our Front Desk personnel. Sometimes this can be done on the same day as your appointment and sometimes it can take 2-3 days, depending on your insurance and/or the urgency of your situation. Someone will contact you as soon as the referral authorization is obtained. As a patient, it is your responsibility to ensure that your specialist is on your plan. It is also your responsibility to ensure your specialist receives your test results. You should pick-up a copy of your test results from our office and hand deliver them to your specialist. We will not fax test results and it is possible that the specialist will not see you without these. Please understand that it can sometimes take a few weeks to get an appointment with a specialist. This is not something we have control over. Durable Medical Equipment: All requests for DME products (walkers, wheelchairs, nebulizers, etc) will be denied if the request is not initiated by the patient. This is for your protection as well as ours. Dismissal: If you are dismissed from the practice it means you can no longer schedule appointments, get medication refills or consider us to be your doctor. You must locate another physician at another practice. You can use many search engines on the internet, look in the local yellow pages under Physicians & Doctors, or you may want to contact the Florida Medical Association at for assistance in locating another physicians who may be accepting new patients. Common Reasons for Dismissal Failure to keep appointments, frequent no-shows Noncompliance, which means you won t follow physician instructions about an important health issue Abusive to staff Failure to pay your bill Leaving the hospital AMA while under our physician s care Dismissal Process We will send a letter to your last known address, via certified mail, notifying you that you are being dismissed. If you have a medical emergency within 30 days of the date on this letter, we will see you. After that, you must find another doctor. We will forward a copy of your medical record to your new doctor after you let us know who it is and sign a release form. (SEE NEXT PAGE FOR FINANCIAL POLICIES

8 Financial Policies We would like to thank you for Individualized Medicine, LLC as your medical provider. We have written this policy to keep you informed of our current financial policies. No Insurance: Payment is due at the time of service, if it is paid in full in cash, we offer 30% percent discount. If you are unable to pay your balance in full, you will need to make prior arrangements with our Front Desk personnel. Insurance: Although we are contracted with several insurance companies, it is your responsibility to make sure that our physician is in your plan. It is also your responsibility to know your insurance benefits. As a courtesy to our patients we will file primary insurance forms from our office. We do not file secondary insurance except for Medicare Recipients. In order to do this we will require information from you. We will need all your demographic and insurance information prior to your appointment. We will also request an update on this information approximately every six months thereafter. We ask that at the time of your appointment you bring your insurance card and a photo ID as well as any other forms that will assist in making sure that your claim is filed correctly. At the time of service you will be responsible for all fees that are not covered by your insurance, including copays, co-insurance, deductibles and non-covered services or items received. The co-pay cannot be waived by our practice, as it is a requirement placed on you by your insurance carrier. We strive to be as accurate as possible in calculating your responsibility but, with so many variations in policies and fee schedules, we are not always exact. You may receive a statement from our office for any balance due. It is your responsibility to provide our office correct insurance information and to notify us of any insurance changes. If you fail to provide our office with correct insurance information, please be advised that the entire balance may be turned over to patient responsibility. Payments: For your convenience we accept cash, checks, debit/credit cards (Visa, MasterCard), and money orders. Returned Checks: Any check returned by your bank for any reason will be due in cash within 15 days of notification. The amount due will be the face value of the check, in addition to a $15.00 Returned Check Charge. If two checks are returned within a six month period, we may request you to make payment only by cash or money order for all future payments. Third Party Litigations: The practice will not become involved in disputes arising from third party claims (i.e., automobile accidents, liability claims, worker s compensation, etc.). Disability, Insurance Forms, Attending Physician Statements, FMLA: There will be a charge of $25.00 for the completion of medical forms or you may be required to schedule an appointment. Payment is due at the time that you pick-up these forms. Please allow 7-10 days for the completion of these forms. If you would like the forms mailed to you or the insurance, payment will be due prior to mailing. FMLA forms require that you come in for an appointment. Medical Records: We will provide you a copy of your medical records upon request and for a fee. You will need to sign a letter of release prior to having them copied. Please allow up to 30 days for this request to be processed. Lab Work: A limited number of lab services will be billed by our office. All other services will be billed by the contracted lab. You may receive a bill from Quest Diagnostics, PCMC Outpatient Lab or LabCorp. Please contact their billing department prior to calling our office. We do not have access to their billing information. If necessary call our office at Billing: If you receive a bill from us, it is because we believe the balance is your responsibility. Please contact your insurance company first, if you think there is a problem. If you have any questions about your bill, please call our office immediately. If you cannot pay your entire balance, please call to make payment arrangements. Collections: Accounts that are not paid within 30 days begin our in house collection process. If your balance becomes 65 days old, your account may be referred to an outside collection agency, your doctor will be notified,and you may be subject to dismissal from the practice. (PLEASE SEE ACKNOWLEDGEMENT ON NEXT PAGE)

9 A COPY OF THESE POLICIES WILL BE PROVIDED AT YOUR REQUEST. PLEASE INFORM THE RECEPTIONIST. Acknowledgement I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: o Conduct, plan and direct my treatment and follow-up among multiple healthcare providers who may be involved in that treatment directly and indirectly. o Obtain payment from third-party payers. o Conduct normal healthcare operations such as quality assessments and physician certifications. I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may submit a request to obtain a current copy of the Notice of Privacy Practices either in person at 6100 St Johns Avenue, Suite 4 or by mail to PO Box 100 Elkton, FL I understand that I may request in writing, that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. I acknowledge that I have reviewed a copy of the Individualized Medicine, LLC Office and Financial and Notice of Privacy Policies and have been provided a copy of said policies if I so requested. Signature of Patient or Guardian Date

10 INDIVIDUALIZED MEDICINE, LLC NOTICE OF PRIVACY POLICIES 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. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT OUR OFFICE MANAGER. OUR OBLIGATIONS: We are required by law to: Maintain the privacy of protected health information Give you this notice of our legal duties and privacy practices regarding health information about you Follow the terms of our notice that is currently in effect HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION: The following describes the ways we may use and disclose health information that identifies you ( Health Information ). Except for the purposes described below, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer. For Treatment. We may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care. For Payment. We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment. For Health Care Operations. We may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the obstetrical or gynecological care you receive is of the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities. Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose Health Information to contact you to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

11 Research. Under certain circumstances, we may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Health Information. SPECIAL SITUATIONS: As Required by Law. We will disclose Health Information when required to do so by international, federal, state or local law. To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat. Business Associates. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract. Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation. Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military. Workers Compensation. We may release Health Information for workers compensation or similar programs. These programs provide benefits for work-related injuries or illness. Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

12 Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime. Coroners, Medical Examiners and Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties. National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law. Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations. Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution. USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT Individuals Involved in Your 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. Disaster Relief. We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so. YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES The following uses and disclosures of your Protected Health Information will be made only with your written authorization: 1. Uses and disclosures of Protected Health Information for marketing purposes; and 2. Disclosures that constitute a sale of your Protected Health Information Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.

13 YOUR RIGHTS: You have the following rights regarding Health Information we have about you: Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to Office Manager, PO Box 100, Elkton, FL or by fax to (386) We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review. Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record. Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information. Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to Office Manager, PO Box 100, Elkton, FL Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to Manager, PO Box 100, Elkton, FL Please allow us 30 days to provide this information to you. Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to Office Manager, PO Box 100, Elkton, FL We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us out-of-pocket in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment. Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

14 Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests. Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our web site, To obtain a paper copy of this notice, please request from our front office staff. CHANGES TO THIS NOTICE: We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page, in the top right-hand corner. COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact our Office Manager. All complaints must be made in writing to Office Manager, PO Box 100, Elkton, FL You will not be penalized for filing a complaint.