Request to Limit Confidential Communication Consent:
At times our office may need to contact you regarding your care. Please read, sign, and date below.
You have the right to revoke this authorization at any time.
I hereby authorize Advice for Optimal Wellness and their staff to contact me on my preferred contact number listed on file.
I hereby authorize Advice for Optimal Wellness and their staff to leave a detailed VM on my preferred
contact number.
Please contact our office to notify of any changes to your preferred contact information.
Advice for Optimal Wellness, Inc. - Notice of Privacy Practices
This notice describes how health information about you may be used and disclosed and how you can
get access to your individually identifiable health information. Please review this notice carefully.
Our commitment to your privacy
Our practice is dedicated to maintaining the privacy of your individually identifiable health information (als
o called protected health information, or PHI). In conducting our business, we will create records regarding
you and the treatment and services we provide to you. We are required by law to
maintain the confidentiality of health information that identifies you, and we must let you know how we may use and disclose your PHI, your privacy rights in your PHI, and our obligations concerning the use
and disclosure of your PHI.
The terms of this notice apply to all records containing your PHI that are created or retained by
our practice. We reserve the right to revise or amend this Notice of Privacy Practices, and any revision
or amendment will be effective for all of your records that we create or maintain. You may request a copy
of our most current Notice at any time. If you have questions about this Notice, please
contact any of our team members.
We may use and disclose your PHI in the following ways:
1. Treatment. The people who work for our practice may use or disclose your PHI in order to treat you or to
assist others in your treatment. We may also disclose your PHI to others who may assist in your care, such
as your spouse, children or parents, and we may disclose your PHI to other health care providers for
purposes related to your treatment.
2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for
the services and items you may receive from us, and we may disclose your PHI to other entities to assist
in their billing and collection efforts. If you choose to pay the full charge out-of-pocket you have the
right to restrict your health plan's access to certain information.
3. Health care operations. Our practice may use and disclose your PHI to operate our business such
as in quality of care and business planning activities and we may disclose your PHI to other entities to
assist in their health care operations.
4. Disclosures required by law. Our practice will use and disclose your PHI when we are required to do so
by law.
5. Use and disclosure of your PHI in certain special circumstances to entities authorized by law to collect
it: Our practice may disclose your PHI to public health authorities, health oversight agencies, law
enforcement officials, and workers' compensation and similar programs. We may also disclose your PHI in
response to a court or administrative order, or when necessary to reduce or prevent a serious threat to
your health and safety or the health and safety of
another individual or the public, or for intelligence and national security activities.
6. Your rights regarding your PHI: You have the following rights regarding the PHI that we maintain about
you.
Confidential communications. You have the right to request in writing that our practice
communicate with you about your health and related issues in a particular manner or at a certain
location. Our practice will try to accommodate reasonable requests.
Requesting restrictions. You have the right to request in writing a restriction in our use or disclosure of
your PHI for treatment, payment, or health care operations. We
are not required to agree to your request; however, if we do agree, we are bound by our agreement except
when otherwise required by law, in emergencies or when the information is necessary to treat you.
Inspection and copies. You have the right to inspect and obtain an electronic copy of the PHI that may be
used to make decisions about you, including patient medical records and billing records, but
not including psychotherapy notes. You must
submit your request to inspect and/or obtain a copy of your PHI in writing to us.
Copies to others. You may request in writing a that we share your pH I with other types of third parties, such as employers. We will not share your PHI with these other types of third parties
without your written consent.
Amendment. You may ask us in writing to amend your health information if you believe it is
incorrect or incomplete.
Accounting of disclosures. You have the right to request in writing
an "accounting of disclosures." An "accounting of disclosures" is a list of certain nonroutine disclosures our practice has made of your PHI for purposes not related to treatment, payment, or
operations. Use of your PHI as part of our routine patient care is not required to be documented.
Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint in
writing with our practice or with the Offices for Civil Rights - U.S. Dept of Health and Human Services. You
will not be penalized for filing a complaint.
Right to provide an authorization for other uses and disclosures. Our practice will obtain your written
authorization for uses and disclosures for marketing or sale, or that are not identified by
this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclo
sure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no
longer use or disclose your PHI for the reasons described in the authorization.
Right to
notification. You have the right to receive notifications whenever a breach of your unsecured PHI occurs. A
gain, if you have any questions regarding this notice or our health information privacy
policies, please let us know. You may also request a more detailed version of this notice which includes
examples of uses and disclosures, and further details about making written submissions.
Individual Rights
1. In addition to all applicable statutory and constitutional rights, every individual receiving services has
the right to:
a. Choose from available services and supports, those that are consistent with the
Service Plan, culturally competent, provided in the most integrated setting in the community and
under conditions that are least restrictive to the individuals liberty, that are least intrusive
to the individual and that provide for the greatest degree of independence;
b. Be treated with dignity and respect;
c. Participate in the development of a written Service Plan, receive services consistent with that plan and
participate in periodic review and reassessment of service and support needs, assist in
the development of the plan, and to receive a copy of the written Service Plan;
d. Have all services explained, including expected outcomes and possible risks;
e. Confidentiality, and the right to consent to disclosure in accordance with ORS 107.154, 179.505,
179.507, 192.515, 192.507, 42 CFR Part 2 and 45 CFR Part 205.50.
f. Give informed consent in writing prior to the start of services, except in a medical emergency or as
otherwise permitted by law. Minor children may give informed consent to services in the
following circumstances:
- Under age 18 and lawfully married;
- Age 16 or older and legally emancipated by the court; or
- Age 14 or older for outpatient services only. For purposes of informed consent, outpatient service
does not include service provided in residential programs or in day or partial hospitalization programs;
g. Inspect their Service Record in accordance with ORS 179.505;
h. Refuse participation in experimentation;
i. Receive medication specific to the individuals diagnosed clinical needs, including medications used to tr
eat opioid dependence;
j.
Receive prior notice of transfer, unless the circumstances necessitating transfer pose a threat to health an
d safety;
k. Be free from abuse or neglect and to report any incident of abuse or neglect without being subject to
retaliation;
I. Have religious
freedom;
m Be free from seclusion and restraint;
n. Be informed at the start of services, and periodically thereafter, of the rights guaranteed by this rule;
o.Be informed of the policies and procedures, service agreements and fees
applicable to the services provided, and to have a custodial parent, guardian, or representative, assist with
7
understanding any information presented;
p. Have family and guardian involvement in service planning and delivery;
q. Make a declaration for mental health treatment, when legally an adult;
r. File grievances, including appealing decisions resulting from the grievance;
s. Exercise all rights set forth in ORS 109.610
through 109.697 if the individual is a child, as defined by these rules;
t. Exercise all rights set forth in ORS 426.385 if the individual is committed to the Authority; and
u. Exercise all rights described in this rule without any form of reprisal or punishment.
2. Notification of Rights: The provider must give to the individual and, if appropriate the guardian, a
document that describes the applicable individual's rights as follows:
a. Information given to the individual must be in written form or, upon request, in an alternative
format or language appropriate to the individuals need;
b. The rights, and how to exercise them, must be explained to the individual, and if appropriate, to her or his guardian; and
c. Individual rights must be posted in writing in a common area.