CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION, INC.
D/b/a JACKSON-HINDS COMPREHENSIVE HEALTH CENTER
GENERAL CONSENT FOR DIANOSIS AND TREATMENT:
GENERAL CONSENT TO CARE:
I, the undersigned, for myself or a minor child or another person for whom I have authority to sign, having registered at Jackson-Hinds Comprehensive Health Center (JHCHC) for the purpose of obtaining health services, do hereby voluntarily consent to such diagnosis and treatment service, as ordered by a provider, dentist or other qualified health care provider of JHCHC. This consent includes my consent for all medical services rendered under the general or specific instructions of a provider; including treatment by a mid-level provider (Nurse Practitioner or Physician Assistant), and other health care providers or the designees under the direction of a physician, as deemed reasonable and necessary.
I recognize that I have the right to refuse any specific diagnostic or treatment service without jeopardizing my right to receive services at the heath center. I also recognize that I will be asked to sign a specific consent, as needed, for surgical and other special procedures including general and/or extensive local anesthesia.
I recognize that, according to the laws of the State of Mississippi, parental consent is not required in the case of a minor seeking treatment of a sexually transmitted infection or a female, regardless of age or marital status, seeking diagnostic or treatment services in connection with pregnancy or childbirth.
I agree and acknowledge that JHCHC is not liable for the actions or omissions of, or the instructions given by the physician, dentist or other qualified health care provider of JHCHC. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the result of treatments or examinations at JHCHC facilities. Further, I authorize the health center to furnish requested patient information to requisite legal, health, social and government entities, as needed.
AFTER HOUR ASSISTANCE
For after hour assistance, please call (601) 362-5321. An On-Call Representative will be available to assist you.
JHCHC’s NOTICE OF PRIVACY PRACTICES
I acknowledge that I have received a copy of JHCHC’s Notice of Privacy Practices, which describes how medial information about me may be used and disclosed and how I can get access to this information.
USE AND DISCLOSE OF INFORMATION
I understand that JHCHC will use and disclose my health information for the purposes of treatment, payment, and healthcare operations. I understand, acknowledge and consent to the release of my personal health information for the purposes outlined in this section, as described in the Notice of Privacy Practices which has been offered to me, and as may otherwise be permitted by law. I understand and acknowledge that JHCHC may record medical and other information related to my treatment in paper, electronic, photographic, video and other formats and that such information will be used in the course of my treatment, for payment purposes and to support healthcare operations. I give consent for my treating physicians and other health care providers to exchange information with other health care professionals and providers about my prior and current health conditions to facilitate treatment. I understand that telemedicine (defined as the use of medical information exchanged from one site to another via electronic communications for the health of the patient, including consultative, diagnostic, and treatment services) may be employed to facilitate my medical care. All electronic transmission of data will be restricted to authorized recipients in compliance with the Federal Health Insurance Portability and Accountability Act (HIPPA) and applicable state privacy laws.
PATIENT RIGHTS AND RESPONSIBILITITES
I understand that I have the right, and the responsibility, to participate in my care and treatment. I understand that I have the right to be informed about the treatment being recommended, and the responsibility to ask questions if I do not understand it. I agree to provide accurate and complete information about my health history and presenting complaint, to agree upon a treatment plan, and follow that plan. I agree to participate and cooperate in my own care and treatment. I understand that my health care providers will treat me with respect, and I agree to do the same for them. Further information can be found in the Patient Rights and Responsibilities pamphlet, which has been offered to me.
RESPONSIBILITY FOR PAYMENT
In consideration of the services provided to me by JHCHC, I agree to pay JHCHC professionals involved in my care for all services and supplies provided to me. If private health insurance, Medicare, Medicaid, other governmental or other insurance programs cover my treatment, I authorize JHCHC to bill any such insurer for all charges incurred by me in connection with my diagnosis, care and treatment. My insurance coverage may provide that some amount of the bill will remain my personal responsibility, such as my deductible, co-payment, co-insurance or charges not covered by my health insurance, Medicare, Medicaid or any other programs for which I am eligible. I understand that certain payments may be required at the time of, or in advance of, services being provided. I also understand I will be billed for any charges not paid by my insurer, and I will be responsible for paying them.
CONSENT TO E-PRESCRIBING
E-Prescribing is defined as a physician’s ability to electronically send error free, accurate, and understandable prescriptions directly to a pharmacy from the point of care. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care. E-Prescribing greatly reduces medication errors and enhances patient safety. The Medicare Modernization Act (MMA) of 2003 listed standards that have to be included in an e-Prescribe program. These include:
• Formulary and benefit transactions – Gives the prescriber information about which drugs are covered by the drug benefit plan.
• Medication history transactions – Provides the physician with information about medications the patient is already taking to minimize the number of adverse drug events.
• Fill status notification – Allows the prescriber to receive an electronic notice from the pharmacy telling them if the patient’s prescription has been picked up, not picked up, or partially filled.
By signing this consent form you are agreeing that Jackson-Hinds Comprehensive Health Center can request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes.
Understanding all the above, I hereby provide informed consent to Jackson-Hinds Comprehensive Health Center to enroll me in the e-Prescribe Program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction.
NOTICES OF PRIVACY PRACTICES
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.
A federal regulation, known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA Privacy Rule), requires all medical records and individually identifiable health information used or disclosed by Jackson-Hinds Comprehensive Health Center (JHCHC) in any form, whether electronically, in writing, or orally, are kept confidential. The HIPAA Privacy Rule gives you, the patient, the right to understand and control how your health information is used, collect and stored in a medical record. JHCHC is the parent organization to 11 health centers and 27 school base sites. This is your medical record; which is the property of JHCHC, but the information in the medical records belong to you. Your records are a requires us to address many specific things in this notice.
OUR COMMITMENT TO PROTECTING HEALTH INFORMATION ABOUT YOU
In this notice, JHCHC describe the ways that JHCHC may use and disclose health information about our patients. The HIPAA Privacy Rule requires that JHCHC protect the privacy of health information that identifies a patient or may be used to identify a patient. This information is called “Protected Health Information” or “PHI.” This notice describes your rights as our patient and our obligations regarding the use and disclosure of PHI. JHCHC is required by law to:
• Maintain the privacy and security of PHI about you.
• Give you this Notice of our legal duties and privacy practices with respect to PHI.
• Comply with the terms of our Notice of Privacy Practices that is currently in effect.
JHCHC is required to abide by the terms of this notice, which JHCHC may change from time to time. Any new notice will be effective for all PHI that JHCHC maintains at that time. JHCHC will also provide you with a copy of the revised notice upon your request.
HOW JHCHC MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU
For uses and disclosures relating to treatment, payment, or health care operations, JHCHC does not need an authorization to use and disclose your medical and behavioral health information.
Treatment: JHCHC may use and disclose PHI about you to provide, coordinate or manage your health care and related services. JHCHC may consult with other health care providers regarding your treatment and coordinate and manage your health care with others. For example, JHCHC may use and disclose PHI when you need a prescription, lab work, an x-ray, or other health care services. In addition, JHCHC may use and disclose PHI about you when referring you to another health care provider so that the health care provider has the information necessary to treat you.
Payment: JHCHC may use and disclose PHI so that JHCHC can bill and collect payment for the treatment and services provided to you. Before providing treatment or services, JHCHC may share details with your health plan concerning the services you are scheduled to receive. For example, JHCHC may ask for payment approval from your health plan before JHCHC provides care or services. JHCHC may use and disclose PHI to find out if your health plan will cover the cost of care and services JHCHC provides. JHCHC may use and disclose PHI to confirm you are receiving the appropriate amount of care to obtain payment for services. JHCHC may use and disclose PHI for billing, claims management, and collection activities. JHCHC may disclose PHI to insurance companies providing you with additional coverage. JHCHC may disclose limited PHI to consumer reporting agencies relating to collection of payments owed to us. JHCHC may also disclose PHI to another health care provider or to a company or health plan required to comply with the HIPAA Privacy Rule for the payment activities of that health care provider, company, or health plan. For example, JHCHC may allow a health insurance company to review PHI for the insurance company’s activities to determine the insurance benefits to be paid for your care.
Health Care Operations: JHCHC may use and disclose PHI in performing business activities that are called health care operations. Health care operations include doing things that allow us to improve the quality of care JHCHC provides and to reduce health care costs.
Required by Law: JHCHC may use and disclose PHI as required by federal, state, or local law. Any disclosure complies with the law and is limited to the requirements of the law.
Public Health Activities: JHCHC may use or disclose PHI to public health authorities or other authorized persons to carry out certain activities related to public health. To prevent or control disease, injury, or disability. To report disease, injury, birth, or death. To report child abuse or neglect. To report reactions to medications or problems with products or devices regulated by the federal Food and Drug Administration or other activities related to quality, safety, or effectiveness of FDA-regulated products or activities. To locate and notify persons of recalls of products they may be using. To notify a person who may have been exposed to a communicable disease in order to control who may be at risk of contracting or spreading the disease. To report to your employer, under limited circumstances, information related primarily to workplace injuries or illness, or workplace medical surveillance.
Abuse, Neglect, or Domestic Violence: JHCHC may disclose PHI in certain cases to proper government authorities if JHCHC reasonably believes that a patient has been a victim of domestic violence, abuse, or neglect.
Health Oversight Activities: JHCHC may disclose PHI to a health oversight agency for oversight activities including, for example, audits, investigations, inspections, licensure and disciplinary activities conducted by health oversight agencies.
Lawsuits and Other Legal Proceedings: JHCHC may use or disclose PHI when required by a court or administrative tribunal order. JHCHC may also disclose PHI in response to subpoenas, discovery requests, or other required legal processes.
Law Enforcement: Under certain conditions, JHCHC may disclose PHI to law enforcement officials. These law enforcement purposes include: Limited requests for identification and location purposes; Legal processes required by law; Suspicion that death has occurred as a result of criminal conduct; In the event that a crime occurs on the premises of the practice; Pertaining to victims of a crime; and In response to a medical emergency not occurring at the office, where it is likely that a crime has occurred.
Coroners and Medical Examiners: JHCHC may disclose PHI to a coroner or medical examiner to identify a deceased person and determine the cause of death.
Organ and Tissue Donation: If you are an organ donor, JHCHC may use or disclose PHI to organizations that help procure, locate, and transplant organs in order to facilitate an organ, eye, or tissue donation and transplantation.
Research: JHCHC may use and disclose PHI about you for research purposes under certain limited circumstances. JHCHC must obtain a written authorization to use and disclose PHI about you for research purposes except in situations where a research project meets specific, detailed criteria established by the HIPAA Privacy Rule.
To Avert a Serious Threat to Health or Safety: JHCHC may use or disclose PHI about you in limited circumstances when necessary to prevent a threat to the health or safety of a person or to the public. This disclosure can only be made to a person who is able to help prevent the threat.
Specialized Government Functions: Under certain circumstances JHCHC may disclose PHI. For certain military and veteran activities, including determination of eligibility for veteran’s benefits and where deemed necessary by military command authorities. For national security and intelligence activities. To help provide protective services for the president and others. For the health or safety of inmates and others at correctional institutions.
Disclosures required by HIPAA Privacy Rule: JHCHC is required to disclose PHI to the Secretary of the United States Department of Health and Human Services when requested by the Secretary to review our compliance with the HIPAA Privacy Rule. JHCHC is also required in certain cases to disclose PHI to you upon your request to access PHI or for an accounting of certain disclosures of PHI about you.
Workers’ Compensation: JHCHC may disclose PHI as authorized by workers’ compensation laws or other similar programs that provide benefits for work-related injuries or illness.
Decedents: In case of patient death, JHCHC may make relevant disclosures to the deceased’s family and friends under essentially the same circumstances such disclosures JHCHC is permitted when the patient was alive; that is, when these individuals were involved in providing care or payment for care unless the decedent had expressed a contrary preference.
Childhood Immunizations: JHCHC may disclose immunizations to schools required to obtain proof of immunization prior to admitting the student so long as the physicians have and document the patient or patient’s legal representative’s “informal agreement” to the disclosure.
OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION REQUIRE YOUR AUTHORIZATION
All other uses and disclosures of PHI about you will only be made with your written authorization. If you have authorized us to use or disclose PHI about you, you may revoke your authorization at any time, except to the extent JHCHC has acted based on the authorization. You understand that JHCHC is unable to take back any disclosures JHCHC has already made with your permission, and that JHCHC is required to retain our records of the care that JHCHC provided you.
YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU
Under federal law, you have the following rights regarding PHI about you:
Right to Request Restrictions: You have the right to request additional restrictions on the PHI that JHCHC may use for treatment, payment and health care operations. You may also request additional restrictions on our disclosure of PHI to certain individuals involved in your care that otherwise are permitted by the Privacy Rule. JHCHC is not required to agree to your request. If JHCHC does agree to your request, JHCHC is required to comply with our agreement except in certain cases, including where the information is needed to treat you in the case of an emergency. To request restrictions, you must make your request in writing to our Compliance Officer. In your request, please include (1) the information that you want to restrict (2) how you want to restrict the information and (3) to whom you want those restrictions to apply. You also have the right to request that any services performed that were paid for in full by you and not billed to your insurance company not be disclosed- this request must be made in writing. For example, for services you request no insurance claim be filed and for which you pay privately, you have the right to restrict disclosures for these services for which you paid for out of pocket.
Right to Receive Confidential Communications: You have the right to request that you receive communications regarding PHI in a certain manner or at a certain location. For example, you may request that JHCHC contacts you at home, rather than at work. You must make your request in writing to our Compliance Officer. You must specify how you would like to be contacted (for example, by regular mail to your post office box and not your home). JHCHC is required to accommodate agreed upon reasonable requests.
Right to Access, Inspect and Copy: You have the right to request the opportunity to access, inspect and receive a copy of PHI about you in certain records that JHCHC maintains. This includes your medical and billing records but does not include any psychotherapy notes or information gathered or prepared for a civil, criminal, or administrative proceeding. JHCHC may deny your request to access, inspect and copy PHI only in limited circumstances. If JHCHC denies your access, JHCHC will give you written reasons for the denial and explain any right to have the denial reviewed. Please contact our Compliance Officer if you have questions about access to your medical record. If you request a copy of PHI about you, JHCHC may charge you a reasonable fee for the copying, postage labor and supplies used in meeting your request.
Right to Amend: You have the right to request that JHCHC amends PHI about you as long as such information is kept by or for our office. To make this type of request you must submit your request in writing to our Compliance Officer. You must also give us a reason for your request. JHCHC may deny your request in certain cases.
Right to Receive an Accounting of Disclosures: You have the right to request an “accounting” of certain disclosures that JHCHC has made of PHI about you. This is a list of disclosures made by us other than disclosures made for treatment, payment, and health care operations. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. The first list that you request in a 12-month period will be free, but JHCHC may charge you for our reasonable costs of providing additional lists in the same 12-month period. JHCHC will tell you about these costs, and you may choose to cancel your request at any time before costs are incurred. In some limited circumstances, you have the right to ask for a list of the disclosures of your health information JHCHC has made during the previous six years. The list will not include disclosures made to you; for purposes of treatment, payment or healthcare operations, for which you signed an authorization or for other reasons for which JHCHC is not required to keep a record of disclosures. There will be no charge for up to one such list each year. There may be a charge for more frequent requests.
Right to a Paper Copy of this Notice: You have a right to receive a paper copy of this notice at any time. You are entitled to a paper copy of this notice.
Right to supply an alternate address: You have the right to ask that JHCHC send you information at an alternative address or by alternative means. JHCHC will consider your request, but are not legally bound to agree to the restriction. JHCHC will agree to your request as long as it is reasonably easy for us to do so.
Right to Notification: In the event of an unauthorized disclosure or access to your PHI, JHCHC will contact you promptly as required by law.
If you believe your privacy rights have been violated, you may file a complaint with us and/or the United States Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints. JHCHC will take no retaliatory action against you for filing a complaint. JHCHC supports your right to the privacy of your health information.
If you have questions about this Notice or any complaints about our privacy practices, please contact our Compliance Officer either by phone or in writing as follows: Attention: Chief Compliance Officer; Jackson-Hinds Comprehensive Health Center; 3502 West Northside Drive; Jackson, Mississippi 39213; Tel: 601-362-5321.