By signing this form, I confirm that I have fully read this contract and that I am responsible for the information in each section.
Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
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. If you have any questions about this Notice please contact us by sending a signed note at the above address.
This Notice of Privacy Practices describes how we may use and disclose your protected health information 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 access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by accessing our website, calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.1. Uses and Disclosures of Protected Health Information Uses and Disclosures of Protected Health Information Based Upon Your Written ConsentYou will be asked by your physician to sign a consent form. Once you have consented to use and disclosure of your protected health information for treatment, payment and health care operations by signing the consent form, your physician will use or disclose your protected health information as described in this Section 1. Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the physician’s practice. Following are examples of the types of uses and disclosures of your protected health care information that the physician’s office is permitted to make once you have signed our consent form. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided consent.o Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you when we have the necessary permission from you to disclose yourprotected health information. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providingassistance with your health care diagnosis or treatment to your physician.o Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevantprotected health information be disclosed to the health plan to obtain approval for the hospital admission.o Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office.We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We will share your protected health information with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact us by sending a written note at above address to request that these materials not be sent to you. Uses and Disclosures of Protected Health Information Based upon Your Written AuthorizationOther uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to ObjectWe may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.o Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. 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. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved inyour health care.o Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your physician shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your physician or another physician in the practice is required by law to treat you and the physician has attempted to obtain your consent but is unable to obtain your consent, he or she may still use ordisclose your protected health information to treat you.o Communication Barriers: We may use and disclose your protected health information if your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to ObjectWe may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:o Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance withthe law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.o Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating withthe public health authority.o Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreadingthe disease or condition.o Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this informationinclude government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.o Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.o Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.o Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.o Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.o Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.o Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.o Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.o Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.o Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.2. Your RightsFollowing is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physician and the practice use for making decisions about you. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact us by sending a written request if you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by supplying us with a signed statement specifying your requests. This document will be placed in your permanent file. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing by mail You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for 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. Please contact us by sending a written request if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.3. ComplaintsYou may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by contacting us by sending a written note detailing your complaint. We will not retaliate against you for filing a complaint.
I acknowledge that I have received a copy of the HIPAA Notice of Privacy Practices of Harmony Medical Clinic, LLC effective March, 2020 and have read it carefully.
Telemedicine if the delivery of medical services using interactive audio and visual ( video) electronic systems where the provider and the patient are not in the same physical location. The interactive electronic systems Inc. network and software security protocols to protect patient information and safeguard the data exchanged.
A computer and a webcam with microphone or any other appropriate device to video conference using HIPAA compliant online company specializing in telemedicine.Patient is required to be physically present within the state of Kansas at the time of service.Potential Benefits
Telemedicine provides convenience and increased accessibility to addiction care for individuals who are unable to be treated face-to-face due to temporary circumstances such as being away at college or an extended stay away from home or having a physical limitation preventing travel to our office.
As with any medical procedure, there may be potential risks associated with the use of a telemedicine. These risks include, but may not be limited to:
Therapy conducted online is technical in nature and problems may occasionally occur with internet connectivity. Difficulties with hardware, software, equipment, and/or services supplied by a third party may result in service interruptions. Any problems with Internet availability or connectivity are outside the control of the Provider and the Provider makes no guarantee that such services will be available or work as expected. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video conferencing, the Provider will call the patient back at the phone number provided on this form.Information transmitted may not be sufficient ( for example; poor resolution of video) to allow for appropriate medical decision making by the psychiatrist or therapist.The provider may not be able to provide treatment to the patient using interactive electronics equipment not provide for or arranged for emergency care that the patient may require in case of connection failureDelays and medical evaluation and treatment may occur due to deficiencies or failures of the equipment.Although highly unlikely, security protocols can fail, causing a breach of privacy of confidential medical information.A lack of access to all the information that might be available in a face-to-face visit but not in a telemedicine session may result in errors in medical judgment.My Rights
I understand that the laws that protect her privacy and confidentiality of medical information also applied to telemedicine.I understand that the technology used by the provider is encrypted to prevent unauthorized access to my private medical information.I have the right to withhold or withdraw my consent to the use of telemedicine during the course of my care at any time.I understand that my withdrawal of consent will not affect any future care or treatment. I understand that the provider has a right to withhold or withdraw his or her consent for the use of telemedicine during the course of my care at any time.I understand that the provider would not record any of our telemedicine session without written consent.I understand that the provider will not allow any other individual to listen to, review or record my telemedicine session without my expressed written permission.My Responsibilities/Expectations
I agree to take full responsibility for the security of any communication or treatment information involved with my own computer and with my own physical locationI understand that I am responsible for using this technology in a secure in private location so that others cannot hear my conversation.I understand that the company that the Provider has chosen to conduct online appointment ( see guidelines) is an independent company specializing in HIPAA compliant telemedicine. My Provider has no responsibility for that company’s operation or security of my protected health information. In addition, the company might send the emails or communications, such as appointment reminders. I understand that the provider is not responsible for this communication. If I am receiving an unwanted commnication from the company, I will call/contact the company directly and address my concerns with them.I will not record any telemedicine sessions without written consent from the provider. I will inform the provider if any other person can hear or see any part of our session before the session begins.I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins and I agreed to revert to a telephone voice session utilizing the indicated backup telephone number provided below should a video connection not function properly. If I am experiencing any technical difficulties.I have read and understand that all of the clinic policies of Harmony Medical Clinic apply to all telemedicine as well as all in person visits.I understand that I agree to be seen face to face at least once every months to maintain therapeutic services and a provider/patient relationship.I consent to paying fees that are the same as an in-office visit.I understand that a telemedicine appointment is scheduled the same as an in-office appointment would be, and should I not be available for the appointment or cancel it less than one full business day in advance, there will be a charge for a missed appointment for the time my Provider has reserved for the scheduled appointment.I understand that in case of Life-threatening emergency situations, my provider can call for emergency services or police/911 for assistance.Patient Consent to the Use of Telemedicine
I have read and understand the information provided in the preceding pages regarding telemedicine. I have discussed this information with my provider and all my questions have been answered to my satisfaction.
I hereby give my informed consent for the use of telemedicine in my medical care and authorize the provider to use telemedicine in the course of my diagnosis and treatment.