From: NGuinn555@comcast

From: NGuinn555@comcast.net
Sender: IMPcohort2@yahoogroups.com
Mailing-List: list IMPcohort2@yahoogroups.com; contact IMPcohort2-owner@yahoogroups.com
Date: Wed, 23 Aug 2006 19:07:04 +0000
Subject: [IMPcohort2] patient hippa rights thingie
Reply-To: IMPcohort2@yahoogroups.com

Here's my version of a document that patients sign when they start the practice. (I did not hire a lawyer to write this - sevreal docs starting up together shared versions of this.)

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM.

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

AS WELL AS ASSIGNMENT AND RELEASE

I have been presented with a copy of the Notice of Privacy Practices of Nancy Guinn MD, LLC.

I hereby give my consent for Nancy Guinn MD, LLC to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). (Nancy Guinn MD, LLC’s Notice of Privacy Practices provides a more complete description of such uses and disclosures.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. Nancy Guinn MD, LLC reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Nancy Guinn MD, LLC Privacy Officer at 2741 Indian School Rd NE, Albuquerque, NM, 87104.

With this consent, Nancy Guinn MD, LLC may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others.

With this consent, Nancy Guinn MD, LLC may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as well as any items pertaining to my clinical care, including laboratory results among others as long as they are marked Personal and Confidential.

With this consent, Nancy Guinn MD, LLC may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as well as any items pertaining to my clinical care, including laboratory results.

I have the right to request that Nancy Guinn MD, LLC restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Nancy Guinn MD, LLC’s use and disclosure of my protected health Information (PHI) to carry out treatment, payment and healthcare operations (TPO).

Unless otherwise indicated to Nancy Guinn MD, LLC, I have medical insurance and assign directly to Nancy Guinn MD, LLC all medical benefits, if any, otherwise payable to me for service rendered. I understand that I may be financially responsible for all charges whether or not paid by insurance. I authorize this signature on all my insurance submissions.

If I have Medicare, I request that payment of authorized Medicare benefits be made on my behalf to Nancy Guinn MD, LLC for any services furnished me by Nancy Guinn MD, LLC. I authorize any holder of PHI to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for the related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 of the HCFA-1500 form, or elsewhere or other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, and noncovered services. Coinsurance and the deducti

ble are based upon the charge determination of the Medicare carrier.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Nancy Guinn MD, LLC may decline to provide treatment to me.

_________________________________ ___________

Signature of Patient or Legal Guardian Date

_________________________________ __________________________________

Print Name of Patient Print Name of Legal Guardian