If you would like to receive future correspondence regarding updates, promotions, news, etc please provide us with the following information and your preferred point of contact.
Your information will NEVER be given to a third party, nor will you be spammed. This information is for our office use only.
ADDITIONAL INSURANCE (IF APPLICABLE)
"I request that payment of authorized insurance benefits be made to Agilus Health, Inc. I authorize any medical information about myself needed to determine these benefits or the benefits payable for related services to be released to the insurance company and it's agents."
**We file your insurance as a courtesy to you. Your insurance coverage is ultimately a contract between you and your insurance company. If for some reason, whether it is pre-existing, failure to receive claim, etc they do not pay the claim, it is necessary that you understand that you are responsible for the balance and will pay for all services rendered to you by our clinicians through our office.
At Agilus Health, Inc, we are moving toward a very digital world. We take great importance in capturing as many moments throughout our clinic as possible. Most of these captured, digital moments are promoted online via Facebook, Instagram and other social media platforms, as well as on television. Unless we have additional consent from you individually, we will never show your face any any of our photographs/videos that are publicly displayed and/or promoted in some other way for marketing purposes. But this agreement is to inform you that you MIGHT be photographed or videotaped during your treatment, or any other activity within the clinic, but your face will NOT BE SHOWN unless otherwise agreed to.
You do have the right to completely decline even the “blurred” image of yourself to be publicly posted, so please provide the appropriate information below if it pertains to you.
"I hereby authorize Agilus Health, Inc to photograph/videotape me for the purpose of identification (patient chart), evaluation, progress documentation, educational marketing, and/or demonstration or treatment and/or progression or treatment or public and/or non public education."
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED ANY DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Uses and Disclosures
Treatment. Your health information may be used by staff members or disclosed to other heath care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.
Health care operations. Your health information may be used a necessary to support the day-to-day activities and management of Agilus Health, Inc. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
Law enforcement. Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting.
Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purposes other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.
Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes when financial remuneration is involved. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of Notice of Privacy Practices your protected health information that contains genetic information that will be used for underwriting purposes.
Additional Uses of Information
Appointment reminders. Your health information will be used by our staff to send you appointment reminders.
Information about treatments. Your health information may be used to send you information on the treatment and management of your medical condition that you may find interesting.
We may also send you information describing other health-related products and services that we believe may interest you.
You have certain rights under the federal privacy standards. These include:
• The right to request restrictions on the use and disclosure of your protected health information
• The right to receive confidential communications concerning your medical condition and treatment
• The right to inspect and copy your protected health information
• The right to amend or submit corrections to your protected health information
• The right to receive an accounting of how and to whom your protected health information has been disclosed
• The right to receive a printed copy of this notice
Agilus Health, Inc. Duties
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices outline in their notice. In the event of a breach of unsecured protected health information, if your information has been compromised it is our duty to notify you.
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit.
The revised policies and practices will be applied to all protected health information we maintain.
Requests to Inspect Protected Health Information
You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting Receptionist or Office Manager. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:
Agilus Health, Inc.
1305 Texas Ave.
Alexandria, LA 71301
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise related against for filing a complaint.
The name and address of the person you may contact for further information concerning our privacy practices is:
Jenny Smith, CFO
This notice is effective on or after September 5, 2013
Acknowledgement of Notice of Privacy Practices
Agilus Health, Inc. reserves the right to modify the privacy practices outlined in the notice.