For More Information or to Report a Problem. If you have any questions about your rights, my duties, or my practices and procedures regarding protected health information, please contact the Secretary of the Department of Health and Human Services at 000 Xxxxxxxxxxxx Xxxxxx, X.X. Washington, D.C. 20201 or by calling (000) 000-0000. Complaints to the Secretary must be filed in writing on paper or electronically and must be made within 180 days of when you became aware of, or should have been aware of, the incident giving rise to your complaints. By law, you cannot be penalized for filing a complaint. Your signature below indicates that you have read this document and have had the opportunity to have any questions answered to your satisfaction. Signed Date Signature of Patient Signed Date Signature of Parent, Guardian or Personal Representative (if applicable) Signed Date Parker Pediatrics & Adolescents Psychology Parker Pediatrics & Adolescents, P.C. Page 2 of 2 Rev 07/18 00000 Xxxxxxxxx Xxx, Xxxxx 000 Parker, Colorado 80138 Telephone: 000-000-0000 Fax: 000-000-0000 / xxx@xxxxxxxxxxxxxxxx.xxx Serving the Parker community since 1982 Website: xxx.xxxxxxxxxxxxxxxx.xxx
For More Information or to Report a Problem. If have questions and would like additional information, you may contact the Administrative Assistant at 000-000-0000 ext. 250 If you believe your privacy rights have been violated, you can file a complaint with the Director of The Community Counseling Center, or with St. Luke’s Director of Human Services. There will be no retaliation for filing a complaint.
For More Information or to Report a Problem. If you have questions or would like additional information about our privacy practices, you may contact the Privacy Officer, 0000 Xxxxxxxx Xxx, Xxxxxxxxx XX 00000 or by telephone at (000) 000-0000. If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint. Effective Date
For More Information or to Report a Problem. If you have questions and would like additional information, you may contact the practice’s staff at 000-000-0000. If you believe your privacy right have been violated you can file a complaint with the practice’s Privacy Officer or with your regional office for Civil Rights, U.S. department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. Example of Disclosure for Treatment, Payment and Health Operations We will use your health information for treatment. For example: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In the way the physician will know how you are responding to treatment. We will also provide your physician or a subsequent health care provider with a copy of various reports that should assist him or her in treating you once you are discharged from the hospital. We will use your health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you as well as your diagnosis, procedures, and supplies used. We will use your health information for regular health operations. For example: We will share your relevant health information with other providers involved in your care to assist in the coordination of your care. This may include specialist, hospital, clinics and other individuals or organizations prior to or after us who have provided you with health care. Business associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and radiology, certain laboratory test, and copy service used when making copies of your health record. When these services are contracted we may disclose your health information to our business associate so they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, we require the business associate to appropriately safeguard your information.
For More Information or to Report a Problem. If you have questions and would like additional information, you may contact our nursing community's Privacy Officer, who is the Administrator. If you believe that your privacy rights have been violated, you file a complaint with us. These complaints must be in writing on a form provided by us. The complaint form may be obtained from the Administrator, and when completed should be returned to him. You may also file a complaint with the secretary of the federal Department of Health and Human Services. There will be no retaliation for filing a complaint. Effective date: April 10, 2003 XXXXXXXX RESIDENTIAL HOME PERSONAL FUNDS AUTHORIZATION FORM RESIDENT RESIDENT NUMBER DATE The purpose of this form is to request and authorize the Brattleboro Mutual Aid Association, Inc. (BMAA) to hold and dispense my personal funds as I request. BMAA will keep complete records of all deposits and disbursements of my funds and will provide me or my designated financial representative (or both) a monthly report of the transactions within my account. I understand that all funds will be deposited in an interest bearing account with Brattleboro Savings and Loan Association and that there is no limit* on the amount of funds I may keep in my personal needs account. I further understand that I will be requested to sign a receipt when money is either deposited or withdrawn from my account and that this personal funds authorization can be withdrawn at any time by me or my designated financial representative upon written notification to BMAA. Signature of Resident
For More Information or to Report a Problem. If you have questions and would like additional information, please ask your clinician. He/she will provide you with additional information or put you in contact with the designated Privacy Officer. If you are concerned that your privacy rights have been violated or you disagree with a decision we have made about access to your health information, you may contact the Privacy Officer. We respect your right to privacy of your health information. There will be no retaliation in any way for filing a complaint with the Privacy Officer of our agency or the U.S. Department of Health and Human Services. HIPAA Privacy Authorization for Use and Disclosure of Personal Health Information This authorization is prepared pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations as amended from time to time. You may refuse to sign this authorization. By my signature below, I acknowledge that I have received and read the Notice of Health Information Privacy Practices. I have been provided a copy of, read and understand (Family Tree Project) HIPAA Privacy Notice containing a complete description of my rights, and the permitted uses and disclosures of my protected health information under HIPAA. Further, I acknowledge that any information used or disclosed pursuant to this authorization could be at risk for re- disclosure by the recipient and is no longer protected under HIPAA. Name Last First MI Address: Street City State Zip Date of Birth: Client Signature: Today’s Date: Parent/Guardian Signature (if client under 18) For office use only I attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained. Reason: Clinician Signature Date Individual HIPAA Provider Number of Clinician Completing Form:
For More Information or to Report a Problem. 8.5.1 If you have questions and/or would like additional information, you may contact our facility's Privacy Officer at 712-563-2651 ext. 234.
For More Information or to Report a Problem. If you have questions and would like additional information, or you believe your privacy rights have been violated, you can file a complaint with Xxxxx Xxxxxxxx, 00 Xxxxxxxxxx Xxxx, Xxxxxxxxx, XX 00000 at 000- 000-0000. Or you may contact the Secretary of the Federal Health and Human Services Department.
For More Information or to Report a Problem. If you have any questions, please call Xxxxxx Counseling at (000) 000-0000 Effective Date: April 14, 2003 I have received a copy of XXXXXX COUNSELING SERVICES, P.C., PRIVACY NOTICE, effective 4-14-03. I hereby give consent to Xxxxxx Counseling Services for myself and/or my dependents in the evaluation and treatment regarding my therapy that may be advisable or necessary in their opinion. If this Privacy and Consent form is not agreed to, including what is in our Complete Notice of Privacy Practices, we cannot provide therapy to you. This consent shall hold valid for this and all future visits unless revoked in writing. My signature demonstrates that I have read, understand, and agree to the above.
For More Information or to Report a Problem. If you have questions or would like additional information about the Pharmacy's privacy practices, you may contact our office by writing to 4Care Pharmacy, Privacy Office, 000 Xxxx Xxxxxxx Xxxxxx, Layton, UT 840413000 or you may call the office tollfree at 1877477 3229. If you believe your privacy rights have been violated, you can file a complaint with our office or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.
