Your Infinity: Initial Primary Care Visit Intake

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

ABOUT THIS NOTICE

We understand that health information about you is personal and we are committed to protecting your information. We create a record of the care and services you receive at Your Infinity Health. We need this record to provide care (treatment), for payment of care provided, for healthcare operations, and to comply with certain legal requirements. This Notice will tell you about the ways in which we may use and disclose health information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of health information. We are required by law to follow the terms of this Notice that is currently in effect.

WHAT IS PROTECTED HEALTH INFORMATION (PHI)

PHI is information that individually identifies you. We create a record or get from you or from another healthcare provider. health plan. your employer, or a healthcare clearinghouse that relates to:

Your past, present. or future physical or mental health or conditions,
The provision of healthcare to you, or
The past, present, or future payment for your healthcare.
HOW WE MAY USE AND DISCLOSE YOUR PHI

We may use and disclose your PHI in the following circumstances:

Treatment. We may use or disclose your PHI to give you medical treatment or services and to manage and coordinate your medical care.
Payment. We may use and disclose your PHI so that we can bill for the treatment and services you receive from us and can collect payment from you, a health plan, or a third party.
Healthcare Operations. We may use and disclose PHI for our healthcare operations. For example, we may use your PHI to internally review the quality of the treatment and services you receive and to evaluate the performance of our team members in caring for you. We also may disclose Information to physicians, nurses, medical technicians, medical students, and other authorized personnel for educational and learning purposes.
Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services. We may use and disclose PHI to contact you to remind you that you have an appointment for medical care, or to contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you.
Research. We may use and disclose your PHI for research purposes, but we will only do that if the research has been specially approved by an authorized institutional review board or a privacy board that has reviewed the research proposal and has set up protocols to ensure the privacy of your PHI. Even without that special approval, we may permit researchers to look at PHI to help them prepare for research, for example, to allow them to identify patients who may be included in their research project, if they do not remove, or take a copy of, any PHI.
As Required by Law. We will disclose PHI about you 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 PHI when necessary to prevent a serious threat to your health or safety or to the health or safety of others. But we will only disclose the information to someone who may be able to help prevent the threat.
Business Associates. We may disclose PHI to our business associates who perform functions on our behalf or providers with services if the PHI is necessary for those functions or services. For example. we may use another company to do our billing, or to provide transcription or consulting services for us. All our business associates are obligated, under contract with us, to protect the privacy and ensure the security of your PHI.
Workers' Compensation. We may use or disclose PHI for workers' compensation or similar programs that provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose PHI for public health activities. This includes disclosures to: (1) a person subject to the jurisdiction of the Food and Drug Administration (FDA) for purposes related to the quality, safety or effectiveness of an FDA regulated product or activity; (2) prevent or control disease, injury or disability; (3) report births and deaths; (4) report child abuse or neglect; (5) report reactions to medications or problems with products; (6) notify people of recalls of products they may be using; and (7) a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
Abuse, Neglect, or Domestic Violence. We may disclose PHI to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence and the patient agrees or we are required or authorized by law to make that disclosure.
Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure, and similar activities that are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.
Data Breach Notification Purposes. We may use or disclose your PHI 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 PHI in response to a court or administrative order. We also may disclose PHI in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get an order protecting the information requested. We may also use or disclose your PHI to defend ourselves in the event of a lawsuit
Law Enforcement. We may disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes.
Military Activity and National Security. If you are involved with military, national security or intelligence activities or if you are in law enforcement custody, we may disclose your PHI to authorized officials so they may carry out their legal duties under the law.
Coroners, Medical Examiners, and Funeral Directors. We may disclose PHI to a coroner. medical examiner, or funeral director so that they can carry out their duties.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose PHI to the correctional institution or law enforcement official if the disclosure is necessary (1) for the institution to provide you with healthcare; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.
Individuals Involved in Your Care. Unless you object in writing, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that person's involvement in your healthcare. 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.
Payment for Your Care. Unless you object in writing, you can exercise your rights under HIPAA that your healthcare provider not disclose information about services received when you pay in full out of pocket for the service and refuse to file a claim with your health plan.
Disaster Relief. We may disclose your PHI to disaster relief organizations that seek your PHI 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 practicably can do so.
YOUR WRITTEN AUTHORIZATION IF REQUIRED FOR OTHER USES AND DISCLOSURES

The following uses and disclosures of your PHI will be made only with your written authorization:

Most uses and disclosures of treatment notes;
Uses and disclosures of PHI for marketing purposes; and
Disclosures that constitute a sale of your PHI. Other uses and disclosures of PHI 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 PHI under the authorization. But disclosure that we made in reliance on your authorization before you revoked will not be affected by the revocation.
YOUR RIGHTS REGARDING YOUR PHI:

You have the following rights, subject to certain limitations, regarding your PHI:

Inspect and Copy. You have the right to inspect, receive, and copy PHI that may be used to make decisions about your care or payment for your care. We have up to 30 days to make your PHI available to you and we may charge you a reasonable fee for the costs of copying, mailing, or other supplies associated with your request. You can only direct us in writing to submit your PHI to a third party not covered in this notice. 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 or 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.
Summary or Explanation. We can also provide you with a summary of your PHI, rather than the entire record, or we can provide you with an explanation of the PHI which has been provided to you, so long as you agree to this alternative form and pay the associated fees.
Electronic Copy of Electronic Medical Records. If your PHI 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. If the PHI is not readily producible in the form or format you request, your record will be provided in a readable hard copy form.
Receive Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured PHI.
Request Amendments. If you feel that the PHI 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 us. A request for amendment must be made in writing to the Privacy Officer at the address provided at the bottom of this Notice and it must tell us the reason for your request. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
Accounting of Disclosures. You have the right to ask for an “accounting of disclosures,” which is a list of the disclosures we made of your PHI. To request this list or accounting of disclosures, you may submit your request in writing to the Privacy Officer. The first accounting of disclosures you request within any 12-month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the list. We will tell you what the costs are, and you may choose to withdraw or modify your request before the costs are incurred.
Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment, or healthcare operations. We are not required by federal regulation to agree to your request. If we do agree with your request, we will comply unless the information is needed to provide emergency treatment. To request restrictions, you must make your request in writing to the Privacy Officer. Your request must state the specific restriction requested, whether you want to limit our use and/or disclosure, and to whom you want the restriction to apply.
Request Confidential Communications. You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a specific address or call you only at your work number. You must make any such request in writing and you must specify how or where we are to contact you.
Paper Copy of This Notice. You have the right to a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may obtain a copy of this Notice by visiting our website: (your website) or request a paper copy of this Notice by contacting us using the information provided at the bottom of this Notice.
Changes to this Notice. We reserve the right to change this Notice. We reserve the right to make the changed Notice effective for PHI we already have as well as for any PHI we create or receive in the future. A copy of our current Notice is posted in our office and on our website.
Complaints. If you believe your privacy rights have been violated, you may file a complaint in writing with us, or with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.
Contact Information:

Your Infinity Health
325-339-1215

ACKNOWLEDGEMENT OF RECEIPT OF PATIENT NOTICE OF PRIVACY PRACTICES FOR Your Infinity Health

 I acknowledge that I have read and/or received a copy of the Your Infinity Health Patient Notice of Privacy Practices.

I understand that telemedicine is the use of electronic information and communication technologies by a healthcare provider to deliver services to a patient whose location is different from that of the provider. An example of telemedicine is videoconferencing between patient and his/her healthcare provider.

Expected Benefits of Telemedicine:

Improved access to medical care by enabling a patient to remain at or closer to home instead of having to travel to the location of the healthcare provider.
More efficient medical evaluation and management.
Access to care or specialist(s) that are not otherwise available in a patient’s location.
Possible Risks of Telemedicine: As with any medical care option there are potential risks associated with the use of telemedicine. These risks include, but are not limited to, the following:

Delays in medical evaluation and treatment could occur due to deficiency or failure of equipment used to facilitate telemedicine; service interruptions; unauthorized access or other technical difficulties.
The images or audio transmitted may not be of sufficient quality to allow for appropriate medical decision making.
In rare cases, security protocols could fail, causing a breach of privacy of personal medical information.
Patient Consent to the Use of Telemedicine:

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine.
I understand that telemedicine may involve electronic communication of my personal medical information to other medical providers who may be located in other areas, including out of state.
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent in writing at any time by contacting Your Infinity Health via email at info@yourinfinityhealth.com or via phone at 325-339-1215.
I understand that as long as this consent is in force (has not been revoked) Your Infinity Health may provide healthcare services to me via telemedicine without the need to sign another consent form.
I have read and understand the information provided above regarding telemedicine; have discussed it with my medical provider or such assistants as may be designated; and all of my questions have been answered to my satisfaction. I hereby give my informed consent to participate in telemedicine visit(s) and receive care via telemedicine from Your Infinity Health and its designated providers and staff.

At Your Infinity Health, we strive to provide all patients with safe, effective and compassionate care. In order to do so, we need your cooperation and agreement as follows:

I agree to be on time for my appointments, and not miss any without prior arrangement. I understand I may not get a prescription without appointment, and that this may lead to withdrawal symptoms and/or relapse.
I agree to notify clinic staff PRIOR to my appointment if I am not able to keep the appointment for any legitimate reason, such as an emergency. I understand the decision to provide a prescription refill without an appointment — even in the case of an emergency situation — is entirely at the discretion of my provider.
I agree to safeguard my prescription medications against loss and theft at all times. I understand that lost or stolen medications WILL NOT be refilled until the next prescription is due.
I agree to take all prescribed medications exactly as instructed to do so, and not take more than the prescribed amount. I understand that if I run out of medication early because I took more than the prescribed amount, I may not be provided additional medication until the next refill is due; and that this may lead to withdrawal symptoms and/or relapse.
I agree that if I end up with extra medication for any reason (such as taking LESS than the prescribed amount), I will disclose this to my provider at the next appointment so that the subsequent prescription(s) can be adjusted. I understand that I must not keep extra medication (particularly any prescribed controlled substances) in my possession for any reason.
I agree to provide urine samples for drug screening periodically as requested. I understand that Your Infinity Health is a non-punitive treatment program and that urine tests are used by Your Infinity Health staff to ensure my safety and to guide my therapy.
I agree to participate in any additional treatments (such as counseling or mental health care) that may be requested or required by my providers.
I agree to NOT fill or obtain prescriptions for ANY CONTROLLED SUBSTANCES (including opiates, benzodiazepines and stimulants) from any outside provider or facility without discussion and consent from my provider(s) at Your Infinity Health.
I understand that any of the following may be IMMEDIATE GROUNDS FOR DISMISSAL FROM THE PROGRAM WITHOUT ANY FURTHER PRESCRIPTIONS OR TREATMENT:Violent, threatening or hostile behavior towards providers or other staff.
Any tampering or attempts to tamper with the urine sample.
Any diversion or attempts to divert medications in the form of selling or sharing with others.
Frequent or excessive missed appointments.
Repeated discordant urine drug test results, including those that show absence of prescribed medication.
With my signature below, I acknowledge that I have read and understood these policies and agree to abide by them at all times. I understand that violation of ANY part of this agreement may be grounds for dismissal from treatment at Your Infinity Health

I consent to receive Collaborative Care Services through Your Infinity Health or its contracted affiliates. I understand that this means my primary provider, behavioral health manager and a psychiatric specialist or addiction specialist (as applicable) will communicate with each other regarding my plan of care.

I understand that through my participation in this program, my behavioral health manager will communicate with me on a regular basis to monitor my progress and provide therapeutic interventions as needed.

I acknowledge that I am providing this consent voluntarily and that I may terminate my participation in the collaborative care program at any time by informing the practice.