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FIRST MEDCARE PRIMARY CARE CENTER

Protected Health Information & Notice of Privacy Practice


I consent to the use or disclosure of my protected health information by First Medcare Inc. to the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of First Medcare Inc. I understand that diagnosis or treatment of me by First Medcare Inc. staff may be conditioned upon my consent as evidenced by my signature on this document.


I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of First Medcare Inc. First Medcare Inc. is not required to agree to the restrictions that I may request. However, if First Medcare Inc. agrees to a restriction that I request, the restriction is binding on First Medcare Inc. and its staff.


I have the right to revoke this consent, in writing, at anytime, except to the extent that First Medcare Inc. has taken action in reliance on this consent.


My “protected health information” means health information, including my demographic information collected from me and created or received by my physician, and not limited to any other source involved in my health, such as another healthcare provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future healthcare and identifies me, or there is a reasonable basis to believe the information may identify me.


First Medcare Inc.'s Notice of Privacy Practices has been made available to me. I understand I have a right to review First Medcare Inc.'s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of First Medcare Inc. The Notice of Privacy Practices also describes my rights and First Medcare Inc.'s duties with respect to my protected health information.


First Medcare Inc. reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.


FIRST MEDCARE PRIMARY CARE CENTER

Consent for Purposes of Treatment, Payment and Healthcare Operations


Release of Medical Records and Direct Payment:


• I hereby authorize and direct my insurance carrier to pay directly to the provider for benefits due under my insurance plan


• I hereby authorize and direct my provider to release to my insurance company any medical information necessary to process claims.


Financial Responsibility:


• I accept that I am financially responsible for all services rendered on my behalf for which a charge may be associated. I accept personal responsibility for all co-payments, deductibles, and non-covered services, as dictated by my insurance coverage, plus any collection costs for amounts personally owed by me.


Diagnosis and Treatment:


• I hereby authorize my treatment by the staff of First Medcare Inc, or their designees as may in their professional judgment be necessary. This includes direct patient care as well as virtual visits via Telephone or Audio/Video care provided by First Medcare staff or its designees. I hereby acknowledge that no guarantees or assurances have been made to me a concerning the results of findings intended from the examinations or treatment. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily to its content.


Office Use Only

Initial Adult Patient Assesment

(To be completed by Patient)
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New York State Department of Health


Authorization for Access to Patient Information Through a Health Information Exchange Organization

I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose whether or not to allow First Medcare Inc, its practioners and healthcare staff to obtain access to my medical records through the health information exchange organization called Healthix. If I give consent, my medical records from different places where I get health care can be accessed using a statewide computer network. Healthix is a not-for-profit organization that shares information about people’s health electronically and meets the privacy and security standards of HIPAA and New York State Law. To learn more visit Healthix’s website at www.healthix.org.


I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose whether or not to allow First Medcare Inc, its practioners and healthcare staff to obtain access to my medical records through the health information exchange organization called Healthix. If I give consent, my medical records from different places where I get health care can be accessed using a statewide computer network. Healthix is a not-for-profit organization that shares information about people’s health electronically and meets the privacy and security standards of HIPAA and New York State Law. To learn more visit Healthix’s website at www.healthix.org.


I can fill out this form now or in the future. I can also change my decision at any time by completing a new form.

If I want to deny consent for all Provider Organizations and Health Plans participating in Healthix to access my electronic health information through Healthix, I may do so by visiting Healthix’s website at www.healthix.org or calling Healthix at 877-695-4749.


My questions about this form have been answered and I have been provided a copy of this form.

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Details about the information accessed through Healthix and the consent process:


1. How Your Information May be Used. Your electronic health information will be used only for the following healthcare services:


Treatment Services. Provide you with medical treatment and related services.


Insurance Eligibility Verification. Check whether you have health insurance and what it covers.


Care Management Activities. These include assisting you in obtaining appropriate medical care, improving the quality of services provided to you, coordinating the provision of multiple health care services provided to you, or supporting you in following a plan of medical care.


Quality Improvement Activities. Evaluate and improve the quality of medical care provided to you and all patients


2. What Types of Information about You Are Included. If you give consent, the Provider Organization(s) listed may access ALL of your electronic health information available through Healthix. This includes information created before and after the date this form is signed. Your health records may include a history of illnesses or injuries you have had (like diabetes or a broken bone), test results (like X-rays or blood tests), and lists of medicines you have taken. This information may include sensitive health conditions, including but not limited to:


• Alcohol or drug use problems & diagnoses


• Birth control and abortion (family planning)


• Genetic (inherited) diseases or tests


• HIV/AIDS


• Mental health conditions


• Sexually transmitted diseases


• Medication and Dosages


• Diagnostic Information


• Allergies


• Substance use history summaries


• Clinical notes


• Discharge summary


• Employment Information


• Living Situation


• Social Supports


• Claims Encounter Data


• Lab Test


3. Where Health Information About You Comes From. Information about you comes from places that have provided you with medical care or health insurance. These may include hospitals, physicians, pharmacies, clinical laboratories, health insurers, the Medicaid program, and other organizations that exchange health information electronically. A complete, current list is available from Healthix. You can obtain an updated list at any time by Healthix’s website at www.healthix.org or by calling 877-695-4749.


4. Who May Access Information About You, If You Give Consent. Only doctors and other staff members of the Organization(s) you have given consent to access who carry out activities permitted by this form as described above in paragraph one.


5. Public Health and Organ Procurement Organization Access. Federal, state or local public health agencies and certain organ procurement organizations are authorized by law to access health information without a patient’s consent for certain public health and organ transplant purposes. These entities may access your information through Healthix for these purposes without regard to whether you give consent, deny consent or do not fill out a consent form.


6. Penalties for Improper Access to or Use of Your Information. There are penalties for inappropriate access to or use of your electronic health information. If at any time you suspect that someone who should not have seen or gotten access to information about you has done so, call First Medcare Inc; or visit Healthix’s website:www.healthix.org; or call the NYS Department of Health at 518-474-4987; or follow the complaint process of the federal Office for Civil Rights at the following link: http://www.hhs.gov/ocr/privacy/hipaa/complaints/.


7. Re-disclosure of Information. Any organization(s) you have given consent to access health information about you may re-disclose your health information, but only to the extent permitted by state and federal laws and regulations. Alcohol/drug treatment-related information or confidential HIV-related information may only be accessed and may only be re-disclosed if accompanied by the required statements regarding prohibition of re-disclosure.


8. Effective Period. This Consent Form will remain in effect until the day you change your consent choice, death or until such time as Healthix ceases operation. If Healthix merges with another Qualified Entity your consent choices will remain effective with the newly merged entity.


9. Changing Your Consent Choice. You can change your consent choice at any time and for any Provider Organization or Health Plan by submitting a new Consent Form with your new choice. Organizations that access your health information through Healthix while your consent is in effect may copy or include your information in their own medical records. Even if you later decide to change your consent decision they are not required to return your information or remove it from their records.


10. Copy of Form. You are entitled to get a copy of this Consent Form.


FIRST MEDCARE INC. NOTICE OF PRIVACY PRACTICE


Notice of Privacy Practices Effective: May 2020


THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.


If you have any questions about this Notice of Privacy Practices, please contact our Privacy Officer, Debbie Banash at 718-257-7777 ext. 155.


This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or conditions and related health care services.


We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of this Notice at any time. Any revised Notice of Privacy Practices would be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting. Notice of Privacy Practices will be prominently displayed in our office at all times and posted on our website at: www.firstmedcare.com.


1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION


Uses and Disclosures of Protected Health Information Prior to disclosing your protected health information to outside health care providers or to obtain payment, First Medcare Inc. will obtain your general consent, usually at your first visit to our facility.


Treatment: We will use and disclose your protected health information to provide, coordinate or manage your health care and any related treatment. This includes the coordination or management of your health care with a third party that already has obtained your permission to have access to your health information. For example, we would disclose your protected health information, as necessary, to primary care physician. We also may disclose protected health information to other specialist physicians who may be treating you.


Appointment Reminders, Treatment Alternatives, Benefits And Services: In the course of providing treatment to you, we may use your health information to contact you with a reminder that you have an appointment for treatment, services or refills or in order to recommend possible treatment alternatives or health-related benefits and services that may be of interest to you.


Emergencies Or Public Need, Emergencies Or As Required By Law: We may use or disclose your health information if you need emergency treatment or if we are required by law to treat you. We may use or disclose your health information if we are required by law to do so, and we will notify you of these uses and disclosures if notice is required by law.


Payment: Your protected health information will be used, as needed to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services, we provide for you, determining your eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity and undertaking utilization review activities.


Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities for our practice. These activities include, but are not limited to quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to an insurer or accreditation agency which performs chart audits. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may use or disclose your protected health information, as necessary, to contact you to remind you of your scheduled procedure.


We will share your protected health information with third party “business associates” that perform various activities for our practice (e.g., computer consulting company, law firm or other consultants). Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.


We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.


Uses and Disclosures of Protected Health Information Based upon Your Written Authorization


Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke your authorization at anytime, in writing, expect to the extent that First Medcare Inc. (“First Medcare Inc.”) has taken an action in reliance on the use or disclosure indicated in the authorization.


The following uses and disclosures will be made only with your authorization:


• Uses and disclosures for marketing purposes;


• Uses and disclosures that constitute the sale of protected health information;


• Most uses and disclosures of psychotherapy notes (if First Medcare, Inc. maintains these notes)


• Other uses and disclosures not described in the notice


Other Permitted and Required Uses and Disclosures That May Be Made With Your Permission or Opportunity to Object:


Others Involved in Your Health Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based upon our professional judgment.


Information to your family members: Unless prior preference is expressed to First Medcare Inc., a deceased patient's health information may be disclosed to a family or other member or other persons who were involved in the individual's care or payment for health care prior to the individual's death if such protected health information is relevant to person's involvement.


Immunization Disclosure to Schools: Upon your agreement, which may be oral or in writing, First Medcare Inc. may disclose proof of immunization to a school where a State or other law requires the school to have such information prior to admitting the student.


Other Permitted and Required Uses and Disclosures that may be Made without your Consent or Authorization Required by Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law.


Public Health: We may disclose your protected health information for public health activities to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We also may disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.


Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or conditions.


Health Oversight: We may disclose your protected health information to a governmental agency for activities authorized by law, such as audits, investigations, and inspections.


Abuse or Neglect: We may disclose your protect health information to public health authority that is authorized by law to receive reports of abuse or neglect. In addition, we may disclose your protected health information if we believe that your have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information.


Product Monitoring and Recalls: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, and biologic product deviations; to track products; to enable product recalls; to make repairs or replacements, or in connection with post-marketing surveillance, as required by law.


Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.


Law Enforcement: We may disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes included (1) legal processes, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of First Medcare Inc., and (6) medical emergency (not on First Medcare's Inc. premises) and it is likely that a crime has occurred.


Decedents: Health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties. Protected health information does not include health information of a person who has been deceased for more than 50 years.


Organ/Tissue Donation: Your health information may be used or disclosed for cadaver organ, eye or tissue donation purposes.


Criminal Activity: We may disclose your protected health information if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety or a person or the public. We also may disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend and individual.


Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel for authorized military purposes, as required by law.


Workers' Compensation: Your protected health information may be disclosed by us as authorized to comply with workers' compensation laws and other similar legally-established programs.


Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.


Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the federal privacy regulations.


2. YOUR RIGHTS


You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a medical record maintained by First Medcare Inc. for as long as we maintain the protected health information. We may charge you our standard fee for the costs of copying, mailing or other supplies we use to fulfill your request.


You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You also may request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.


In most circumstances, your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. However, if you request us to restrict disclosures to health plans that we would normally make as part of payment or health care operations, we must agree to that restriction if the protected health information relates to health care which you have paid out of pocket in full.


If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction using the form for requests for restrictions on protected health information from the Privacy Officer, or you may provide us your request, in writing. Your request must include (a) the information you wish restricted; (b) whether you are requesting to limit the practice’s use, disclosure, or both; and (c) to whom you want the limits to apply.


You have the right to electronic copies of your protected health information when requested. Where information is not readily producible in the form and format requested, the information must be provided in an alternative readable electronic format as agreed to by you and First Medcare Inc., Inc. may charge a reasonable cost based fee for labor in copying protected health information and postage where you request that information be transmitted via mail or courier.


You have the right to request to receive confidential communications from us by alternative means or at an alternative location. For example, you may ask us to contact you by mail, rather than by phone at home. You do not have to provide us a reason for this request. We will accommodate reasonable requests. We also may condition the accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. Please make this request in writing to our Privacy Officer.


You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you that we maintain. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.


You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This means you may request an amendment of protected health information about you that we maintain. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.


You have the right to an accounting of disclosures excludes disclosures we may have made to you, or to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding other disclosures that occurred up to six years from the date of the request (three years in the case of disclosures from an electronic health record made for treatment, payment or health care operations).


You may request a shorter timeframe. The first list you request within a 12-month period is free of charge, but there is a charge involved with any additional lists within the same 12-month period. We will inform you of any costs involved with additional requests, and you may withdraw your request before you become responsible for any costs.


You have the right to obtain a paper copy of this Notice from us.


You have the right to opt out of fundraising communications (if First Medcare Inc. conducts fundraising).


You have the right to receive to notice in the event of a breach of unsecured protected health information.This means that you will receive notice if a breach of your protected health information is discovered within 60 days of discovery.


3. COMPLAINTS


You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer.


You may contact our Privacy Officer, Debbie Banash at 718-257-7777 ext. 155 for further information regarding the complaint process.