PATIENT MEDICAL HISTORY FORM

I have received, reviewed and understand this practice’s Notice of Privacy Practices written in plain language. The notice provides, in detail, the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice’s legal duties with respect to my information. This includes, but is not limited to:

• A statement that this practice is required by law to maintain the privacy of protected health information.
• A statement that this practice is required to abide by the terms of the notice currently in effect.
• Types of uses and disclosures that this practice is permitted to make for each of the following purposes: treatment, payment, and health care operations.
• A description of each of the other purposes for which this practice is permitted or required to use or disclose protected health information without my written consent or authorization.
• A description of uses and disclosures that are prohibited or materially limited by law.
• A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization.
• My individual rights with respect to protected health information and a brief description of how I may exercise these rights in relation to:
  • The right to complain to this practice if I believe my privacy rights have been violated, and that no retaliatory actions will be used against me in the event of such a complaint.
  • The right to request restrictions on certain uses and disclosures of my protected health information, and that this practice is not required to agree to a requested restriction.
  • The right to receive confidential communications of protected health information. The right to inspect and copy protected health information.
  • The right to amend protected health information.
  • The right to receive an accounting of disclosures of protected health information.
  • The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request.

I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by, this practice. If changes to the policy occur, this practice will provide me an updated Notice of Privacy Practices upon request.

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice of Privacy Practices describes how our practice may use and share your health information with others to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to view and amend your Protected Health Information ("PHI"). PHI information is information about you and the services you have received. This would include information such as your name, address, date of birth, diagnosis, treatment, or other information that could identify you and your past, present, or future physical or mental health or treatment you receive.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

Your PHI may be used and shared by your physician, our office staff, and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you, paying our claims for health care provided to you, and any other use permitted or required by law.

Treatment: We will use and share your PHI information to provide, coordinate, or manage your health care and any related services. This includes coordinating or managing your health care with a third party (for example, sending PHI information to a specialist as part of a referral/referral).

Payment: Your PHI information will be used, as necessary, to receive payments for claims related to the services provided to you. For example, obtaining approval for a hospital stay may require that your PHI be shared with the health plan to obtain approval for hospital admission. Or by submitting billing information to your insurance company or state payer such as Medicaid or Medicare. We may also disclose your PHI to our partners such as the billing company, the claims processing company, and other third parties who process insurance claims.

Company Operation: We may use or disclose, as necessary or appropriate, your PHI information to support our health care operations. These activities include, but are not limited to, quality assessment activities, employee review activities, medical student training, licensing, health supervision audits or inspections, marketing, and fundraising activities, and conducting or arranging for other business activities. In addition, we may use a registration sheet at the registration desk where you will be asked to sign your name and indicate your doctor. We may also call you by name in the waiting room when your doctor is ready to see you. We may also provide your PHI to our attorneys, accountants and consultants to ensure that we comply with applicable laws.

Appointment Reminders: We may use and disclose your PHI information to contact you and remind you of your medical appointments by phone or email.

Treatment Alternatives: We may use and disclose your PHI information to inform you of possible treatment options and health-related benefits and services that may be of interest to you.

ADDITIONAL USES AND DISCLOSURES

As described below, we may use and disclose your PHI information in various other situations without your authorization.

 

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As Required by Law: We may disclose your PHI information when required to do so under federal, state, or local law.

For Public Health Activities: We may disclose your PHI information to public health or other authorities charged with the prevention or control of disease, injury, and disability or uploaded with the collection of public health data.

Abuse and Neglect: We may disclose your PHI information to public officials who are authorized by law to receive reports of abuse, neglect, and domestic violence.

Health Oversight Activities: We may also disclose your PHI information to organizations that provide oversight of health care facilities and services, such as government agencies and benefit programs.

For Legal Proceedings: We may disclose your PHI information in the course of judicial or administrative proceedings, including in response to a subpoena or court order.

For Law Enforcement Purposes: We may disclose your PHI information to law enforcement officials in certain circumstances where we suspect criminal conduct or to report a crime on our premises or in emergency situations.

A Coroner and For Organ Donation: We may disclose your PHI information to coroners or medical examiners for the purpose of identifying a deceased person, determining the cause of death, or as otherwise required. We may also disclose your PHI information to funeral directors, as necessary, to carry out their duties.

For Research: We may disclose your PHI information to researchers if an institutional review board has approved such disclosures because appropriate safeguards have been taken to ensure the protection of your PHI information.

To Prevent Serious Harm: We may disclose your PHI information when necessary to prevent a serious threat to the safety and health of the public or a person, including yourself.

Government Functions: We may disclose your PHI information to military officers if you are an active military member or to determine veterans' eligibility and/or benefits. We may also disclose your PHI information for national security, intelligence activities, the protection of the President, and to determine the suitability of officers to work in a public office. If you are an inmate of a correctional facility, we may disclose your PHI information to correctional facility officers.

Workers' Compensation: We may disclose your PHI as we are authorized to comply with workers' compensation laws or similar programs that provide benefits for work-related injuries or illnesses.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES

Other uses and disclosures not described in this notice will only be made with your authorization or opportunity to object unless required by law. This includes most uses and disclosures of psychotherapeutic notes (where applicable), uses and disclosures for marketing purposes, and disclosures that constitute a sale of your PHI information. You may cancel any authorization you have granted, at any time, in writing to our Privacy Officer at the address below.

YOUR RIGHTS

The following are statements of your rights in relation to PHI information.

You have the right to inspect and request a copy of your PHI information as long as we maintain your medical record.

You must request a copy of your registration in writing from our Privacy Officer at the address below. We may charge you a reasonable fee, under Mississippi law, for processing your application and copying your record.

 

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In certain circumstances we may deny your request and you may have the right to request that our denial be reviewed. Depending on the reason for the denial, another licensed medical professional may be chosen by us to review your application and the associated denial.

You have the right to request a restriction of your PHI information. This means that you may ask us not to use or share any part of your PHI for the purpose of Treatment, Payment, or Health Care Operations except in cases of emergency.

You may also request that any part of your PHI not be disclosed to family, friends, or other individuals who may be involved in your care. While we will consider any reasonable request for restrictions, we are not required to grant your request unless you request a restriction of certain disclosures of your PHI to a health plan when you have paid for our services in full without charging the health plan.

You have the right to request that your PHI information be disclosed to you on a confidential basis. This includes sending an email to an address other than your home. Your request should indicate how or where you wish to be contacted and should be sent to our Privacy Officer at the address below. We will accommodate reasonable requests.

You have the right to obtain a paper copy of this notice from us upon request at any time. You may ask us for a paper copy of this notice at any time.

You may have the right to request that we amend your PHI if you believe it is incorrect or incomplete, as long as we keep your medical record. To request that we modify your PHI information, you must request it in writing to our office and explain why the modification is necessary. We may deny your request if a) we have not created the PHI, b) the request relates to information we do not maintain, c) the request relates to information that you do not have the right to inspect, such as psychotherapy notes, d) we determine that your PHI is correct and complete. If we deny your request for amendment, you have the right to submit a statement of disagreement to us and we can prepare a response to your statement and provide you with a copy of that response. You have the right to receive accountability for certain disclosures, if any, of your PHI information. Disclosure accounts do not apply to disclosures made for treatment, payment, and health care operations or for disclosures we have made to you or at your request. The first accountability requested in a twelve (12) month period is free of charge, but we may charge you the costs of producing additional accounts during the same twelve (12) month period. The request for a surrender must specify the applicable dates and must be in writing to the Privacy Officer at the address below.

You will receive notifications of breaches of your unsecured PHI. If your PHI information maintained by our office or its business associates has been breached, we will notify you of the situation and take reasonable steps to mitigate any damage that may result from the breach. You have the right to file a complaint with our office or with the Secretary of Health and Human Services if you believe we have violated your privacy rights. You can file a complaint with us by notifying our office. Filing a complaint will not affect your health care services in any way. We reserve the right to change the terms of this notice. If we make revisions, you will be informed by posting the revised notice in the waiting area and on our website.

We are required by law to protect the privacy of your information, provide this Notice of our privacy practices, follow the practices described in this notice, and notify you after a breach of your unsecured PHI information. If you have any questions or complaints, please contact our office.

 

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ACKNOWLEDGEMENT OF RECEIPT

By signing below, you acknowledge that you have received, reviewed, and understand this practice's Notice of Privacy Practices written in plain language. The notice provides, in detail, the uses and disclosures of my protected health information that this practice may perform, my individual rights, how I can exercise these rights, and the practice's legal obligations with respect to my information.

 

I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes with respect to all protected health information residing in, or controlled by, this practice. If there are policy changes, this practice will provide me with an updated Notice of Privacy Practices upon request.

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Insurance Information: I understand that it is my responsibility to provide accurate and up-to-date insurance information to the Provider. This includes the insurance company name, policy number, group number, and any other necessary information. I am aware that insurance coverage varies, and I am responsible for understanding my coverage and any applicable deductibles, co-payments, and out-of-pocket expenses.

Payment Obligation: I understand that I am responsible for all charges incurred for the medical services provided, whether or not they are covered by insurance. This includes, but is not limited to, co-payments, deductibles, non-covered services, and any charges exceeding the limits of my insurance policy. I agree to pay all such charges promptly.

Payment Methods: I agree to make payments for services rendered by the Provider using the following payment methods:

Cash 

Check

Debit Card

Credit Card (Visa, MasterCard, American Express, Discover)

Billing Procedures: I acknowledge that I will receive statements from the Provider outlining the services provided and the corresponding charges. It is my responsibility to review these statements for accuracy and promptly notify the Provider of any discrepancies.

Payment Due Date: Payment for all outstanding balances is due within 30 days of receiving a statement.

Failure to make timely payments may result in additional charges, including interest and collection fees.

Collection Costs: In the event that my account becomes past due and requires the involvement of a collection agency or legal action, I agree to pay all associated collection costs, including but not limited to attorney's fees and court costs.

Financial Assistance: I understand that the Provider may offer financial assistance or payment plan options for patients facing financial hardship. I will contact the Provider to discuss these options if needed.

Changes in Insurance Coverage: I agree to promptly inform the Provider of any changes in my insurance coverage, including changes in policy, coverage termination, or a change in the primary insurance holder.

Authorization for Release of Information: I authorize the Provider to release any necessary medical information to my insurance company for the purpose of processing claims.

 

Acknowledgement of Financial Responsibilities

I have read and understand the terms and conditions outlined in this Financial Responsibility Form. I accept full responsibility for payment of all charges associated with the medical services provided by the Provider.