The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients’ consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.
As our patient we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest.
We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.
You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.
If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.
The patients have a responsibility to the provider/health care organization which include:
- Patients are responsible for keeping appointments and for notifying the health center in advance when unable to keep appointments.
- Patients are responsible for giving truthful information about their present complaints, past illnesses, hospitalizations, medication, and other matters related to their health.
- Patients should provide information about their expectations of, and satisfaction with, the organization.
- Patients should ask questions when they do not understand their care, treatment or services, or what they are expected to do.
- Patients are responsible to follow their Plan of Care, treatment, or services. As agreed they should take prescribed medication, keep referral appointments, obtain laboratory and x-ray tests, etc.
- Patients should express any concerns about their ability to follow the proposed plan of care, treatment or services.
- Patients should accept their share of responsibility for the outcomes of care, treatment, or services if they do not follow the care, treatment, or services plan.
- Patients should follow the Heavens Medical, PLC Policies, and Procedures.
- Patients should be respectful of Heavens Medical providers and staff. Verbal, mental, physical or sexual abuse by patients towards other patients or staff is not acceptable.
- Patients should not use profanity or be disruptive to other patients. Violence or threatening behavior is not acceptable.
- Patients should be respectful of Heavens Medical, PLC property as well as other patient’s property (refrain from damaging, stealing, etc.).
- Patients should meet any financial obligation agreed to with the organization.