NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), 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 health care providers who may be involved in that treatment directly or indirectly.
- Obtain payment from third-party payers.
- Conduct normal health care operations such as quality assessments and physician certifications.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The notice is provided in layers: This top layer briefly summarizes how we handle your health information, and the attached bottom later provides further details of our privacy policies and procedures.
How We May Use & Disclose Your Health Information: We use health information about you for treatment, to get paid for treatment, for administrative purposes, and to evaluate the quality of care that you receive. For example, your health information may be shared with other providers to whom you are referred. Information may be shared by paper, electronic mail, fax, or other methods. We may use or disclose your health information without your authorization for several reasons. But beyond those situations, we will ask for your written authorization before using or disclosing your health information. If you sign as authorization to disclose information, you can later revoke it to stop any future uses and disclosures.
Your Rights: In most cases, you have the right to look at or get a copy of your health information that we use to make decisions about you. If you request copies, we may charge you a cost-based fee. You also have the right to request a list of certain types of disclosures of your information that we have made. If you believe your health information is incorrect or information I am missing, you have the right to request that we correct the existing information or add the missing information.
Our Legal Duty : We are required by law to protect the privacy of your health information, provide this notice about our privacy practices, follow the privacy practices that are described in this notice, and seek your acknowledgement of receipt of this notice. We may change our policies at any time. For more information about our privacy policies, contact the front desk.
Privacy Complaints: If you are concerned that we have violated your privacy rights, or policies, or if you disagree with a decision we made about access to your health information, you may contact the front desk. You also may send written complaints to U.S. Department of Health and Human Services. The person at the front desk can provide you with the appropriate address upon request.
Medicare/Medicaid/Patient Certification/Release Information & Payment Request
I certify that the information given to me in apply for payment under the Title XVII and/or XIX, of the Social Security Act is correct. I authorize a holder of behavioral health information about me to release to the Social Security Administration or its intermediaries or carriers, any information needed for this or a relation to Medicare claim. I request that payments of authorized benefits are made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare or Medicaid for payment to me. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY HEALTH INSURANCE DEDUCTIBLES & CO-PAYMENTS.
Assignment of Insurance Benefits: I hereby authorize, request, and direct all assigned insurance companies to pay directly to Instic Health providers the amount due mien pending claims for these behavioral health benefits under the respective policies. I agree that should the amount be insufficient to cover the entire expense; I will be responsible for payment of the entire bill.
Guarantee of Payment: For value received, the undersigned does agree and promise to pay Instic Health providers all charges and expenses incurred on the treatment of the named patient, including expense not covered by insurance policy presently in force. If any action at law or inequality is brought to enforce the agreement, Instic Health providers will be entitled to reasonable attorney’s fees, court costs, and any other cost of collection incurred. I understand that all bills are payable and become due upon presentation.
Denial of Payment Authorization: Instic Health will make every effort to obtain payment/authorization/preauthorization for all managed care contractual agreements. If however, a denial is received, the patient/guarantor will be responsible for all incurred charges and penalties.
Receipt of Patient’s Rights and Responsibilities, Notice of Privacy Practices and Orientation/Welcome Guide: By my signature on this document, I acknowledge receipt of a Patient’s Rights and Responsibilities pursuant to Florida State 381.026, a Notice of Privacy Practices, and a copy of the Orientation/Welcome Guide prior to, or at the time of admission.
Release of Responsibility & Liability for Personal Valuables: I understand and agree that Instic Health is not responsible for personal valuables or belongings brought into, or claimed to be brought into any of the Instic Health LLC office by named patient/client or his/her agent.