Right to Know of Breach of Unsecured Protected Health Information Sample Clauses

Right to Know of Breach of Unsecured Protected Health Information. You have the right to be notified in the event of a breach of unsecured PHI. PATIENT INFORMATION FORM MEDICARE MEDICARE ID NUMBER Date of Laryngectomy Surgery PATIENT'S NAME (LAST NAME, FIRST NAME, MIDDLE INITIAL) PATIENT'S BIRTHDATE SEX MM | DD | YY M F PATIENT'S ADDRESS (NUMBER, STREET) PATIENTS RELATIONSHIP TO INSURED Self [ ] Spouse [ ] Child [ ] Other [ ] CITY STATE PATIENTS STATUS Single [ ] Married [ ] Other [ ] ZIP CODE TELEPHONE NUMBER (INCLUDE AREA CODE) Employed [ ] Full Time Student [ ] ( ) Part Time Student [ ] PLEASE NOTE: *Leave no blanks * Use Same or N/A (not applicable) * PLEASE READ THE STATEMENTS BELOW * And remember to sign at the bottom of form INSURED'S NAME (LAST NAME, FIRST NAME, MIDDLE INITIAL) INSURED'S ADDRESS (NUMBER, STREET) CITY STATE ZIPCODE TELEPHONE NUMBER (INCLUDE AREA CODE) SECONDARY INSURED’S NAME (LAST NAME, FIRST NAME, MIDDLE) SECONDARY INSURANCE COMPANY SECONDARY INSURED’S ID NUMBER SECONDARY INSURANCE CLAIMS ADDRESS SECONDARY INSURED’S DATE OF BIRTH MM  DD  YY CITY STATE ZIP SECONDARY INSURED’S SEX SECONDARY INSURANCE TELEPHONE M F ( ) I understand that my supplies WILL NOT be covered by I authorize payment of medical benefits directly to the supplier for services furnished. I authorize the release of any medical information necessary to process an insurance claim on my behalf. I give DeanRosecrans permission to appeal on my behalf any decision to deny coverage for the DeanRosecrans stoma supplies. I permit a copy of this authorization to be as valid as the original. By signing below, I also understand that I am responsible for notifying the provider of any changes in my status. Medicare if I am in the hospital, a Skilled Nursing Facility, or receive services from a Home Health Agency. I agree to accept financial responsibility for any such charges. I, the undersigned, state the above facts are true and correct to the best of my knowledge, and I request payment of government benefits either to myself or to the party who accepts assignment. PATIENT’S SIGNATURE DATE Revised 9/23/2015 PLACE IN SELF ADDRESSED ENVELOPE AND RETURNED REFERRING PHYSICIAN'S PRESCRIPTION FORM FOR TRACHEOSTOMA COVERINGS AND/OR COMMUNICATION EQUIPMENT My Patient NAME ADDRESS Must be Filled out had laryngectomy surgery for removal of a cancerous larynx. Medicare Diagnosis Code C32.9 Speech Aid (Artificial Larynx) Replacement supplies (batteries, cords, tubes, etc.) Repairs when needed (Speech Aid) My Patient must use Tracheostoma Filters Daily...
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Related to Right to Know of Breach of Unsecured Protected Health Information

  • Unsecured Protected Health Information “Unsecured Protected Health Information” shall have the same meaning as the term “unsecured protected health information” in 45 CFR § 164.402.

  • Electronic Protected Health Information “Electronic Protected Health Information” means individually identifiable health information that is transmitted by or maintained in electronic media.

  • Protected Health Information “Protected Health Information” shall have the same meaning as the term “protected health information” in Section 160.103 and is limited to the information created or received by Contractor from or on behalf of County.

  • Amendment of Protected Health Information 8.1 To the extent Covered Entity determines that any Protected Health Information is maintained by Business Associate or its agents or Subcontractors in a Designated Record Set, Business Associate shall, within ten (10) business days after receipt of a written request from Covered Entity, make any amendments to such Protected Health Information that are requested by Covered Entity, in order for Covered Entity to meet the requirements of 45 C.F.R. § 164.526.

  • Access to Protected Health Information 7.1 To the extent Covered Entity determines that Protected Health Information is maintained by Business Associate or its agents or Subcontractors in a Designated Record Set, Business Associate shall, within two (2) business days after receipt of a request from Covered Entity, make the Protected Health Information specified by Covered Entity available to the Individual(s) identified by Covered Entity as being entitled to access and shall provide such Individuals(s) or other person(s) designated by Covered Entity with a copy the specified Protected Health Information, in order for Covered Entity to meet the requirements of 45 C.F.R. § 164.524.

  • Data Protection and Privacy: Protected Health Information Party shall maintain the privacy and security of all individually identifiable health information acquired by or provided to it as a part of the performance of this Agreement. Party shall follow federal and state law relating to privacy and security of individually identifiable health information as applicable, including the Health Insurance Portability and Accountability Act (HIPAA) and its federal regulations.

  • Permitted Uses and Disclosures of Protected Health Information Business Associate:

  • Confidentiality of Health Information (a) A Nurse shall not be required to provide her or his manager/supervisor specific information regarding the nature of her or his illness or injury during a period of absence. However, the Employer may require the Nurse to provide such information to persons responsible for occupational health.

  • Use and Disclosure of Protected Health Information The Business Associate must not use or further disclose protected health information other than as permitted or required by the Contract or as required by law. The Business Associate must not use or further disclose protected health information in a manner that would violate the requirements of HIPAA Regulations.

  • Health Information Subject to all applicable privacy laws, the member irrevocably authorises any doctor or other person who may have, or may acquire, any information concerning their health to disclose such information to Specialty Emergency Services, and that this authority shall remain in force for a period of not less than 12 (twelve) months following the expiry date of this Membership Agreement.

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