Patient Demographic & Consent Form
NOTICE OF PRIVACY
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, outlines the ways in which the Prestige Medical Concierge (“Company”), may use and disclose medical information about you, which discloses your individual identity.
Company protects you with respect to disclosure of your Protected Health Information by:
- limiting who may see, use and further disclose this information, and
- informing you of our legal duties and your legal rights respecting this information.
This Notice also outlines Company’s obligations and your rights regarding the use and disclosure of Protected Health Information. Company is required by law to maintain the privacy and security of your Protected Health Information and to notify you promptly following a breach of unsecured Protected Health Information, and to comply with the terms of the Notice that is currently in effect. Your information will not be used or shared other than as described in this Notice unless you provide written approval to do so. If you do provide written approval, you may change your mind at any time by written request.
This Notice summarizes the HIPAA privacy rights and obligations of all parties who have access to your Protected Health Information, including providers of health care services who have direct treatment relationships with you.
Administration of all your rights is placed with the Privacy and Security Officer designated herein, at the end of this Notice (“Privacy and Security Officer”).
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION ABOUT YOU
For Treatment (as Provider). We may use Protected Health Information about you in your treatment. This may include uses and disclosures to provide, coordinate, manage or supplement your health care and related services.
For Payment (as Provider). We may use and disclose Protected Health Information about you to bill or collect for the treatment and services we provide.
For Healthcare Operations (As Provider). We may use and disclose Protected Health Information about you in performing business activities called “healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation certification, licensing or credentialing activities.
As Required by Law. We will disclose relevant Protected Health Information about you when required to do so by federal, state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose Protected Health Information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Law Enforcement. We may release Protected Health Information about you if asked to do so by a law enforcement official such as: in response to a court order, subpoena, warrant, summons or similar process.
Health Oversight Activities. We may disclose Protected Health Information about you to a health oversight agency for oversight activities authorized by law.
National Security and Intelligence Activities. We may release Protected Health Information about you to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.
To your family and friends. We must disclose your health information to a family member, friend or other person to the extend necessary to help with your healthcare or payment for your healthcare, but only if you agree that we may do so.
YOUR RIGHTS WITH RESPECT TO PROTECTED HEALTH INFORMATION
You have the following rights regarding Protected Health Information we maintain about you:
Right to Inspect and Copy. You have the right to inspect and obtain a copy of Protected Health Information about you, with limited exceptions. You may request that we provide copies in a format other than photocopies unless we cannot practically do so. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
Right to Amend. You have the right to request an amendment of Protected Health Information about you for as long as the information is kept by or for the Company. To request an amendment, your request must be made in writing and submitted to the Privacy and Security Officer. In the written request, you must provide a reason that supports your request.
Right to an Accounting of Disclosures. You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities. You can ask for a list of the times we have shared your Protected Health Information for six (6) years prior to the date you ask, who we shared it with, and why.
Right to Request Restrictions. You have the right to request that we place additional restrictions or limitation on our use or disclosure of your Protected Health Information. We are not required to agree with these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Right to Request Confidential Communications. You have the right to request that we communicate with you about Protected Health Information about you by alternative means or at alternative locations. To request confidential communications, you must make your request in writing to the Privacy and Security Officer. Your request must specify how or where you wish to be contacted.
Right to Copies of This Notice. You have the right to paper and electronic copies of this Notice. You may ask us to give you a copy of this Notice at any time.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. All material changes or revisions to the Notice will be prominently posted on the website by the effective date of such changes. The new notice will be available upon request, in our office, and on our web site.
If you believe your privacy rights as described in this Notice have been violated, you may file a complaint with Company or with the Secretary of the U. S. Department of Health and Human Services. To file a complaint with Company, contact the Privacy and Security Officer who will provide you with a copy of the complaint procedure upon request. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
If you have any questions about this Notice, please contact the Privacy and Security Officer.
The following individual is designated by Company for purposes of HIPAA Privacy compliance:
Privacy and Security Officer: Dalia Elizalde, T:772-241-7880
CONSENT FOR TREATMENT
This consent will be effective after the date it is signed for Prestige Medical Concierge.
Consent for Treatment/Care
As patient/parent/authorized representative, I hereby voluntarily give my consent to the rendering of such care including diagnostic procedure, medical and surgical procedure and treatment as prescribed by a duly licensed physician, healthcare facility or their authorized designees, as may in their professional judgment be necessary to provide for the medical, surgical or emergency care for:
As completed in Demographic Form
I have accurately provided the Medical History information, identified all the medical/physical conditions, medications I/patient is taking (including over-the-counter), and known allergies.
I understand that Prestige Medical Concierge depends on information I have provided, and any discrepancies may complicate the treatment, cause injury and/or reduce my chances of successful treatment outcome. If there is any change in any of my medical history, I agree to provide all updated information.
I acknowledge that no guarantee has been made to me as to the effect of such examinations or treatment.
I understand and agree that I assume financial responsibility to all charges for medical and related professional services performed or by a physician and/or healthcare facility. I also understand that an insurance company may not pay the full amount of my charges, and I may be responsible (as a patient, spouse, or the parent of a minor child) for the amount not paid. If I do not have health insurance or have not provided current or accurate insurance information, I am responsible for payment of all charges.
I understand my signature constitutes my acknowledgement that:
- I have read and agreed to the foregoing;
- The diagnostic procedures and/or treatment have been adequately explained to me by the health professional and that I have received all information I desire concerning the same;
- That I authorize the consent to the diagnostic procedures and/or treatment; and
- I am releasing the healthcare facility from liability.
I understand that I may withdraw this consent in writing. My withdrawal will not be effective for actions already taken, or in progress.
I have read this form, received a copy or have been made aware it is available online at the Prestige Medical Concierge website, and I am the patient or authorized to act on behalf of the patient.