I authorize the release of medical information necessary to determine liability to obtain payment. I assign payment of benefits to Firefly After Hours Pediatrics, LLC. Laboratory specimens are sent to Quest Laboratory and Genesis Laboratory unless otherwise specified. I may receive a bill from either laboratory for this service. Copay and Deductibles Are Due At Time of Service.Your Insurance Will Be Contacted To Verify Benefits And Costs.

PAYMENT AUTHORIZATION AGREEMENT

I hereby authorize Firefly After Hours Pediatrics to keep my card (as indicated below) on file for payment and to initiate appropriate payment entries against the listed referenced debit or credit card or HSA card as applicable, as amounts are owed by me. I acknowledge that the initiation of such entries to make payments must comply with the provision of. U.S. law and applicable state laws. I understand and agree that these entries may be made to my debit, credit or HSA card as applicable, periodically to pay amounts owe by me for any balances. I also agree to notify Firefly if the card information listed below changes for any reason. This authorization shall remain in effect until the expiration date of the card or until I communicate to Firefly my intention to cancel authorization in writing

 Notice of Privacy Practices

 

 

Firefly After Hours Pediatrics, LLC

 

 

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.

 

Personally identifiable information about your health, your health care, and your payment for health care is called Protected Health Information.  We must safeguard your Protected Health Information and give you this Notice about our privacy practices that explains how, when and why we may use or disclose your Protected Health Information.  Except in the situations set out in the Notice, we must use or disclose only the minimum necessary Protected Health Information to carry out the use or disclosure.

 

We must follow the practices described in this Notice, but we can change our privacy practices and the terms of this Notice at any time.

 

If we revise the Notice, you may read the new version of the Notice of Privacy Practices on our website at [www.fireflypediatrics.com].  You also may ask for a copy of the Notice by calling us at [203-968-1900] and asking us to mail you a copy or by asking for a copy at your next appointment.

 

 

Uses and Disclosures of Your Protected Health Information That Do Not Require Your Consent

 

We may use and disclose your Protected Health Information as follows without your permission:

For treatment purposes.  We may disclose your health information to doctors, nurses and others who provide your health care.  For example, your information may be shared with people performing lab work or x-rays.

 

To obtain payment.  We may disclose your health information in order to collect payment for your health care.  For instance, we may release information to your insurance company.

 

For health care operations.  We may use or disclose your health information in order to perform business functions like employee evaluations and improving the service we provide.  We may disclose your information to students training with us.  We may use your information to contact you to remind you of your appointment or to call you by name in the waiting room when your doctor is ready to see you.

 

When required by law.  We may be required to disclose your Protected Health Information to law enforcement officers, courts or government agencies.  For example, we may have to report abuse, neglect or certain physical injuries.

 

For public health activities.  We may be required to report your health information to government agencies to prevent or control disease or injury.  We also may have to report work-related illnesses and injuries to your employer so that your workplace may be monitored for safety. 

 

For health oversight activities.  We may be required to disclose your health information to government agencies so that they can monitor or license health care providers such as doctors and nurses.

 

For activities related to death.  We may be required to disclose your health information to coroners, medical examiners and funeral directors so that they can carry out duties related to your death, such as determining the cause of death or preparing your body for burial.  We also may disclose your information to those involved with locating, storing or transplanting donor organs or tissue.

 

 

To avert a threat to health or safety.  In order to avoid a serious threat to health or safety, we may disclose health information to law enforcement officers or other persons who might prevent or lessen that threat.

 

 

For workers' compensation purposes.  We may disclose your health information to government authorities under workers' compensation laws.

 

 

 

Uses and Disclosures of Your Protected Health Information That Offer You an Opportunity to Object

 

 

In the following situations, we may disclose some of your Protected Health Information if we first inform you about the disclosure and you do not object

 

 

 

To your family, friends or others involved in your care.  We may share with these people information related to their involvement in your care or information to notify them as to your location or general condition.  We may release your health information to organizations handling disaster relief efforts.

 

 

Uses and Disclosures of Your Protected Health Information That Require Your Consent

 

 

The following uses and disclosures of your Protected Health Information will be made only with your written permission, which you may withdraw at any time:

 

For research purposes.  In order to serve our patient community, we may want to use your health information in research studies.  For example, researchers may want to see whether your treatment cured your illness.  In such an instance, we will ask you to complete a form allowing us to use or disclose your information for research purposes.  Completion of this form is completely voluntary and will have no effect on your treatment.

 

 

For marketing purposes.  Without your permission, we will not send you mail or call you on the telephone in order to urge you to use a particular product or service, unless such a mailing or call is part of your treatment.  Additionally, without your permission we will not sell or otherwise disclose your Protected Health Information to any person or company seeking to market its products or services to you.

 

  

For any other purposes not described in this Notice.  Without your permission, we will not use or disclose your health information under any circumstances that are not described in this Notice.

 

 

Your Rights Regarding Your Protected Health Information
 

 

You have the following rights related to your Protected Health Information:

 

To inspect and request a copy of your Protected Health Information.  You may look at and obtain a copy of your Protected Health Information in most cases.  You may not view or copy psychotherapy notes, information collected for use in a legal or government action, and information which you cannot access by law.  If we use or maintain the requested information electronically, you may request that information in electronic format.

 

 

To request that we correct your Protected Health Information.  If you think that there is a mistake or a gap in our file of your health information, you may ask us in writing to correct the file.  We may deny your request if we find that the file is correct and complete, not created by us, or not allowed to be disclosed.  If we deny your request, we will explain our reasons for the denial and your rights to have the request and denial and your written response added to your file.  If we approve your request, we will change the file, report that change to you, and tell others that need to know about the change in your file.

 

 

To request a restriction on the use or disclosure of your Protected Health Information.  You may ask us to limit how we use or disclose your information, but we generally do not have to agree to your request.  An exception is that we must agree to a request not to send Protected Health Information to a health plan for purposes of payment or health care operations if you have paid in full for the related product or service.  If we agree to all or part of your request, we will put our agreement in writing and obey it except in emergency situations.  We cannot limit uses or disclosures that are required by law.

 

 

To request confidential communication methods.  You may ask that we contact you at a certain address or in a certain way.  We must agree to your request as long as it is reasonably easy for us to do so. 

 

 

To find out what disclosures have been made.  You may get a list describing when, to whom, why, and what of your Protected Health Information has been disclosed during the past six years.  We must respond to your request within sixty days of receiving it.  We will only charge you for the list if you request more than one list per year.  The list will not include disclosures made to you or for purposes of treatment, payment, health care operations if we do not use electronic health records, our patient directory, national security, law enforcement, and certain health oversight activities.

 

 

To receive notice if your records have been breached.  Firefly After Hours Pediatrics will notify you if there has been an acquisition, access, use or disclosure of your Protected Health Information in a manner not allowed under the law and which we are required by law to report to you.,   We will review any suspected breach to determine the appropriate response under the circumstances.

 

 

To obtain a paper copy of this Notice.  Upon your request, we will give you a paper copy of this Notice. 

 

 

If you have any questions about these rights, please contact us.

 

 

How to Complain about Our Privacy Practices
 

 

If you think we may have violated your privacy rights, or if you disagree with a decision we made about your Protected Health Information, you may file a complaint with our Privacy Officer by writing to [janderson@fireflyafterhours.com].

 

 

You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services by writing to 200 Independence Avenue SW, Washington, D.C. 20201 or by calling 1-877-696-6775.

 

 

We will take no action against you if you make a complaint to either or both of these persons.

 

 

How to Receive More Information About our Privacy Practices
 

 

If you have questions about this Notice or about our privacy practices, please contact our Privacy Officer, [janderson@fireflyafterhours.com].

 

 

Effective Date
 

 

This Notice is effective on July 1, 2020

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 at our main phone number.

This signature is only acknowledgement that you have received this notice of our Privacy Practices.