HIPPA
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of privacy practice.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand you are not required to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.
CONSENT TO EJ HEALTH SOLUTIONS, INC. FOR SERVICES
I request and authorize medical care as my physician, his assistant, or designees (collectively called “The physicians,) may deem necessary or advisable. This care may include, but is not limited to, routine diagnostics, radiology and laboratory procedures, administration of routine drugs, biological and other therapeutics, and routine medical and nursing care. I authorize my physician(s) to perform other additional or extended services in emergency situations if it may be necessary or advisable to preserve my life or health. I understand that my (the patient) care is directed by my physician(s) and that other personnel renders care and services to me (the patient) according to the physician(s) instructions.
- I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees or promises have been made to me concerning the results of such diagnostic procedures or treatments.
- I understand that samples of body fluids and/or tissues may be withdrawn from me (the patient) during routine diagnostic procedures. I authorize EJ Health Solutions, Inc. (“EJHS”) to dispose of the bodily fluids.
- I have been informed and understand that an HIV (human immunodeficiency virus – AIDS) test may be performed on me without my consent if a health professional or EJ Health Solutions, Inc. employee or First Responder sustains an exposure to my blood or other body fluid.
- HIV testing/screening may be performed with verbal explanation and consent. EJHS does not offer anonymous HIV testing. If you want to request an anonymous HIV test, then EJHS can assist you in locating a facility that does such. You have the right to withdraw your consent for the test at any time before the test is complete. You have the right to ask questions and have them answered prior to the test and after results are reported. Screening for Hepatitis or other infectious diseases may also be performed with verbal consent. EJHS will report all positive test results to the Department of Health or other agency, as determined by state and local regulations.
- A drug screen by blood or urine sample may be obtained with verbal consent for purposes of verifying compliance with medication regimens or when abuse or misuse is suspected, or when signs or symptoms of toxicity exist.
ACKNOWLEDGEMENT OF PRIVACY PRACTICES
The EJ Health Solutions, INC Notice of Privacy Practices provides information about how protected health information about me (the patient)- including information about human immunodeficiency virus (HIV), AIDS-related complex (ATC), and acquired immunodeficiency (AIDS); including substance abuse treatment records protected under the regulation 42 Part.2, in the Code of Federal Regulations (if any); and psychological and social services records, including communication made to me to a social worker or psychologist (if any), may be disclosed. I have been offered an opportunity to review the Notice before signing this consent. I understand that the terms of the Notice may change, and I may obtain a revised copy by contacting the local EJ Health Solutions, Inc. office.
- I understand that I have the right to request restrictions on how my protected health information is used, or disclosed for treatment, payment or healthcare operations. My physician(s) and Visiting Physicians Association are not required to agree to this restriction, but if they agree, will be bound by the agreement.
- By signing this form, I acknowledge that I have been offered and/or received the EJ Health Solutions Inc. Notice of Privacy Practices.
AUTHORIZATION TO RELEASE HEALTH INFORMATION
I understand that as part of my healthcare, Visiting Physicians Association, originates, maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that my medication history and formulary benefits may be downloaded from a secure electronic clearinghouse. I understand that this information serves as:
- A basis for planning my care and treatment
- A means of communication among the many health professionals who contribute to my care
- A source of information for applying my diagnosis and surgical information to my bill
- A means by which a third-party payer can verify that services billed were provided
- A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals
I acknowledge that a copy of the Notice of Privacy Practices was provided to me. I understand that I have the following rights and privileges:
- The right to review the notice prior to signing this consent
- The right to object to the use of my health information for directory purposes
- The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations.
I understand that EJ Health Solutions, Inc. is not required to agree to the restrictions requested. I understand, revoke this consent in writing, except to the extent that the organization has already taken action in reliance on thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse as permitted by Section 164.506 of the code of Federal Regulations.
I further understand that EJ Health Solutions, Inc. reserves the right to change its notice and practices, in section 164.520 of the code of federal regulation. Should EJ Health Solutions, Inc. change its notice, they will send a copy of any revised notice to the address provided (whether U.S. mail or, if I via email).
ASSIGNMENT OF INSURANCE BENEFITS
Medicare Certification: I certify that the information provided by me in applying for payment under TITLE XVll of the Social Security Act is correct and request on my behalf all authorized benefits.
I hereby authorize and instruct my insurance carrier to make payment directly to EJ Health Solutions, Inc. For benefits (payments) otherwise payable to me. I agree to personally pay for any charges that are not covered by or collected from any insurance program, including deductibles and coinsurance amounts.
TELEMEDICINE PATIENT CONSENT
Telemedicine Consult:
- Details of your medical history, examinations, x-rays, and tests will be discussed through interactive video, audio, and telecommunication technology.
- A physical examination may take place with video and audio during the Telemedicine Consult.
Confidentiality: All existing laws regarding your access to medical information and copies of your medical records still apply to this telemedicine consultation. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation to information disclosed during this telemedicine consultation.
Rights: You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
You have been advised of all the potential risks and benefits of telemedicine. All your questions have been answered, and you understand the written information provided above.
✓ I agree to participate in a telemedicine consultation for the procedures prescribed above.