Frank W. Shagets M.D.
620 W. 32nd Street, Suite B
Joplin, Missouri 64804
Office Phone (417) 623 - 5111
Notice of Privacy Practices Acknowledgement Form
In the course of providing service to you, we create, receive and store health information about you. It is often necessary to use and share your health information with others to ensure you receive the appropriate medical treatment, receive payment and perform administrative tasks in our office such as filing insurance claims on your behalf.
The Notice of Privacy Practices you have been given describes these uses and disclosures in detail.
As described in our Notice of Privacy Practices, the use and disclosure of you health information for treatment purposes not only includes care and service provided here, but also as may be necessary for you to receive follow-up care from another health professional.
We use and disclose your health information for the purpose of receiving payment for our services which includes: (1) submission to a billing agent or vendor, (2) to third-party payers or insurers for claims review, determination of benefits and payment (3) to auditors hired by third-party payers and insurers and (4) other aspects of payment described in the Notice of Privacy Practices.
When you sign this document, you agree that we may use and disclose your health information for the purpose of treatment, payment and to perform the necessary administrative functions in our office.
You have the right to restrict the use and disclosure of your health information for the purpose of treatment, payment and administrative duties, however as described in our Notice of Privacy Practices, we are not obligated to the restrictions. If we do agree to the restriction is binding on us.
I have read this document and understand it. I consent to the use and disclosure of my health information for the purpose of treatment, payment and administrative functions. I acknowledge that I have received the Notice of Privacy Practices from Frank W. Shagets M.D.
Patient Signature: ______Date: ______
Parent(s) Signature (if minor)______Date: ______
I give permission for test results/messages to be released to: NameRelationship
______
______
May we leave messages on home answering machine? Yes No
Frank W. Shagets M.D.
2700 McClelland Blvd. Ste 204
Joplin, Missouri 64804
Office Phone ( 417 ) 623 - 5111
PATIENT CONSENT FOR USE AND DISCLOSURE
OF PROTECTED HEALTH INFORMATION
I hereby give my consent for Frank W. Shagets M.D. to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Frank W. Shagets M.D. Notice of Privacy Practices provides a more complete description of such uses and disclosures.)
I have the right to review the Notice of Privacy Practices prior to signing this consent.
Frank W. Shagets M.D. reserves the right to revise its Notice of Privacy Practices at
anytime. A revised Notice of Privacy Practices may be obtained by forwarding a
written request to LeaAnna White, Privacy / Compliance Manager, at 2700 McClelland Blvd. Suite 204, Joplin, Missouri64804.
With this consent, Frank W. Shagets M.D. may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others.
With this consent, Frank W. Shagets M.D. may mail to my home or other alternative location anyitems that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.
With this consent, Frank W. Shagets M.D. may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Frank W. Shagets M.D. restrict how it uses or discloses my PHI to carry out TPO.
However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to Frank W. Shagets M.D. to the use and disclosure of my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Frank W. Shagets M.D. may decline to provide treatment to me.
______
Print Name of Patient or Legal Guardian
______
Signature of Patient or Legal GuardianDate
Frank W. Shagets M.D.
2700 McClelland Blvd. Ste 204
Joplin, Missouri 64804
Office Phone ( 417 ) 623 - 5111
CONSENT FORM
Frank W. Shagets M.D. hereby requests ______(hereinafter referred to as “the Patient”) to give their consent to release confidential healthcare information to ______for the purpose of ______when providing required healthcare operations or treatment, and / or to obtain payment for healthcare operations or treatments.
CONDITIONS:
1.The patient understands that their confidential healthcare information is to be used for treatment,
payment or for healthcare operations.
2.The patient further understands that their healthcare information may be disclosed to other healthcare
providers for the purposes of treatment, payment or for healthcare operations.
3.Frank W. Shagets M.D. reserves the right to either honor or terminate the patient's request to limit the
use of the patient's confidential healthcare information.
It is understood that this consent is between Frank W. Shagets M.D. and the Patient named above and shall be maintained and stored under the control of Frank W. Shagets M.D. for a period of six (6) years.
This consent is entered into on this _____ day of ______, 20_____.
COMPLIANCE / PRIVACY MANAGER:PATIENT or LEGAL REPRESENTATIVE
______
Print NamePrint Name
______
SignatureSignature
Note: This form is optional and not required under the HIPAA regulation.
Frank W. Shagets M.D.
2700 McClelland Blvd. Ste 204
Joplin, Missouri 64804
Office Phone ( 417 ) 623 - 5111
PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PHI
I, ______authorize Frank W. Shagets M.D. to use and / or disclose the following protected health information (PHI) to ______. This authorization permits Frank W. Shagets M.D. to use and / or disclose the
following individually identifiable health information about me (specifically describe the
information to be used or disclosed, such as date(s) of services, type of services, level of detail to be released, origin of information, etc.):
______
______
The information will be used or disclosed for the following purpose:
______
If requested by the patient, purpose may be listed as “at the request of the individual.”
The purpose(s) is / are provided so that I can make an informed decision whether to allow release of the information. This authorization will expire on ______.
The Practice will ___ will not ___ receive payment or other remuneration from a third party in exchange for using or disclosing the PHI. I do not have to sign this authorization in order to receive treatment from Frank W. Shagets M.D.. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke thisauthorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to:
LeaAnna White
Privacy / Compliance Manager
Address:
2700 McClelland Blvd, Suite 204
Joplin, Missouri 64804
CityState Zip Code
______
Print Name of Patient or Legal Guardian Date
Signed by:______
Signature of Patient or Legal Guardian Relationship to Patient
PATIENT / GUARDIAN TO BE PROVIDED WITH A SIGNED COPY OF AUTHORIZATION
Frank W. Shagets M.D.
2700 McClelland Blvd. Ste 204
Joplin, Missouri 64804
Office Phone ( 417 ) 623 - 5111
Inspect & Copy PHI
Date ______
Patient’s Name: ______
Address: ______
City, State, Zip: ______
Dear ______:
In accordance with the Final Rule for the Standards for Privacy of Individually Identifiable Health Information (Privacy Rule) issued by the U.S. Department of Health and Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Frank W. Shagets M.D. is unable to honor your request to inspect and obtain a copy of your protected health information (PHI) for the following reason(s):
[ ] Frank W. Shagets M.D. does not possess the information requested.
[ ] You have requested psychotherapy notes, as defined in the Privacy Rule, and
we are not required to allow you to inspect and obtain a copy of your psychotherapy
notes.
[ ] The Privacy Rule does not require the practice to permit you to inspect and
obtain a copy of the requested information because it has been compiled in
anticipation of, or for use in a civil, criminal or administrative action or
proceeding.
[ ] The Privacy Rule does not require the practice to permit you to inspect and
obtain a copy of the requested information because it is subject to or
exempted by the Clinical Laboratory Improvements Amendments (CLIA) of
1988.
[ ] The Privacy Rule does not require the practice to permit you to inspect and
obtain a copy of the requested information because the information was
obtained from someone other than a healthcare provider under a promise of
confidentiality and the access requested would be reasonably likely to reveal
the source of the information.
[ ] The Privacy Rule does not require the practice to permit you to inspect and
obtain a copy of the requested information because the information was/is
being created or obtained in the course of on-going research that includes
treatment and you agreed to the denial of access when you consented to
participate in the research. Your right of access will be reinstated upon the
completion of the research.
[ ] The requested information is contained in records subject to the federal
Privacy Act, 5 U.S.C. §552a, and this denial meets the requirements of that
law. (The Privacy Act of 1974 protects personal information about
individuals held by the federal government.)
[ ] A licensed healthcare professional has determined in his/her professional
judgment that access to the requested information is reasonably likely to
endanger your life or physical safety or the life or physical safety of another
person.
[ ] The requested information makes reference to another person and a licensed
healthcare professional has determined, in the exercise of reasonable
judgment, that the requested access is reasonably likely to cause substantial
harm to such other person.
[ ] You are the personal representative of the subject of the requested
information, and a licensed healthcare professional has determined, in the
exercise of professional judgment, that the requested information should not
be provided to you.
If access to requested information has been denied for any of the last three reasons listed above, you have the right to have the denial reviewed by another licensed healthcare professional who did not participate in this denial. If you choose to have this denial reviewed, please submit a written request to our Privacy / Compliance Manager at:
2700 McClelland Blvd. Suite 204
Joplin, Missouri 64804
Our Privacy / Compliance Manager will respond with a written decision within a reasonable period of time whether or not to ultimately grant or deny access to your PHI as originally requested. You may file a complaint regarding this denial with the Privacy Manager referenced above or with the Secretary of the U.S. Department of Health and Human Services. Complaints to the Secretary must be in writing, name the Practice, describe the acts / omissions believed to violate the Privacy Rule, and be filed within 180 days of the alleged violation.
Regards,
LeaAnna White
Privacy / Compliance Manager
Frank W. Shagets M.D.
2700 McClelland Blvd. Ste 204
Joplin, Missouri 64804
Office Phone ( 417 ) 623 - 5111
RESTRICTION AGREEMENT
The undersigned patient hereby limits and / or restricts the release of confidential healthcare information as specified below to: ______,
(Name of Requestor)
located at ______, for the
(Address)
purpose of: ______.
PATIENT WILL INITIAL IN THE SPACES BELOW:
_____ I hereby request that Frank W. Shagets M.D. restrict the aforementioned individual or company with any and all medical data and confidential healthcare information as indicated below, concerning my healthcare procedures and / or treatment.
____ I understand that Frank W. Shagets M.D. is not required to agree to my request.
MEDICAL INFORMATION TO BE RESTRICTED:
_____ Patient Name ______Patient mailing address
______Patient telephone number ______Patient Occupation
_____ Patient social security number ______Patient employer
_____ Patient spouse name ______Spouse employer
_____ Patient office visits ______Patient medical history
_____ Doctor hospital notes ______Prescription information
_____ Admission date ______Admitting diagnosis
_____ Results of physical examination ______Laboratory data
_____ Diagnostic test reports ______Surgical procedure reports
_____ List of treatments ______List medications
_____ Information from physician consults ______Ancillary personnel notes
_____ Nursing______Other
Patient Name: ______
( Print )
Patient Signature: ______Date:______
Witness Name: ______
( Print )
Witness Signature: ______Date:______
(Note: original to be placed in patient's medical record)
Frank W. Shagets M.D.
2700 McClelland Blvd. Ste 204
Joplin, Missouri 64804
Office Phone ( 417 ) 623 - 5111
REQUEST TO AMENDMENT OF PROTECTED HEALTH INFORMATION
Patient Name: ______Date of Birth: ______
Patient Address: ______
Street: Apartment #
______
City, State Zip
Type of Entry to be Amended: ______
Visit note
Nurse note
Hospital note
Prescription information
Patient history
Please explain how the entry is inaccurate or incomplete.
______
______
Please specify what the entry should say to be more accurate or complete.
______
______
______
Signature of Patient or Legal Guardian Date
Amendment has been: Accepted
Denied
Denied in part, Accepted in part
If denied (in whole or in part)*, check reason for denial:
PHI was not created by this organization.
PHI is not available to the patient for inspection in accordance with the law.
PHI is not a part of patient’s designated record set.
PHI is accurate and complete.
Comments from healthcare provider who provided service:
______
______
______
______
Name of Staff Member Completing Form: ______
Title: ______
______
Signature of Frank W. Shagets M.D. Date
*If your request has been denied, in whole or in part, you have the right to submit a written statement disagreeing with the denial to the practice,
Attn: LeaAnna White
2700 McClelland Blvd. Ste 204
Joplin, Missouri 64804
Office Phone ( 417 ) 623 - 5111
If you do not provide us with a statement of disagreement, you may request that we provide to you copies of your original request for amendment, our denial, and any disclosures of the protected health information that is the subject of the requested amendment. Additionally, you may file a complaint with our Privacy / Compliance Manager referenced aboveor the Secretary of the U.S. Department of Health & Human Services.
*PRACTICE MUST INFORM PATIENT THAT A WRITTEN REQUEST IS REQUIRED, AND THAT THE
PATIENT IS REQUIRED TO PROVIDE A REASON TO SUPPORT THE REQUESTED CHANGE.
Frank W. Shagets M.D.
2700 McClelland Blvd. Ste 204
Joplin, Missouri 64804
Office Phone ( 417 ) 623 - 5111
PATIENT ASSIGNMENT OF PERSONAL REPRESENTATIVE
I, ______am assigning ______as my personal representative(s) and authorize Frank W. Shagets M.D. to disclose my protected health information (PHI) to this individual(s). This authorization permits Frank W. Shagets M.D. to disclose the following individually identifiable health information about me (specifically describe the information to be used or disclosed, such as date(s) of services, type of services, level of detail to be released, origin of information, etc.):
______
______
The information will be used or disclosed for the following purpose:
______
If requested by the patient, purpose may be listed as “at the request of the individual.”
The purpose(s) is / are provided so that I can make an informed decision whether to allow release of the information. This authorization will expire on ______.
The Practice will ___ will not ___ receive payment or other remuneration from a third party in exchange for using or disclosing the PHI. I do not have to sign this authorization in order to receive treatment from Frank W. Shagets M.D. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke thisauthorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to:
LeaAnna White
Privacy / Compliance Manager
Address:
2700 McClelland Blvd. Ste. 204
Joplin, Missouri 64804
______
Print Name of Patient or Legal Guardian Date
Signed by:______
Signature of Patient or Legal Guardian Relationship to Patient
PATIENT / PERSONAL REPRESENTATIVE TO BE PROVIDED WITH A SIGNED COPY OF AUTHORIZATION
Frank W. Shagets M.D.
2700 McClelland Blvd. Ste 204
Joplin, Missouri 64804
Office Phone ( 417 ) 623 - 5111
______
Facsimile Transmittal
Date:______
To:______Fax: # ______
From: ______
Re: ______No. of Pages: ______
CC: ______
______
__ Urgent __For Review __ Please Comment __ Please Reply __Please Recycle
______
Note: The information contained in this facsimile may be privileged and confidential and protected from
disclosure. If the reader of this facsimile is not the intended recipient, you are hereby notified that any reading, dissemination, distribution, copying, or other use of this facsimile is strictly prohibited. If you have received this facsimile in error, please notify the sender immediately by telephone at ( 417 ) 623 – 5111 and destroy this facsimile. Thank you.
Message:
______
______
______
______
Frank W. Shagets M.D.
2700 McClelland Blvd. Ste 204
Joplin, Missouri 64804
Office Phone ( 417 ) 623 - 5111
CONFIDENTIAL COMMUMICATIONS FORM
I______, request that Frank W. Shagets M.D. send my PHI to the alternate location listed below or to contact me at the alternate telephone number listed below:
Alternate address: ______
Street
______
City, State, Zip Code
______
Telephone number
Patient Name: ______
Patient Signature: ______Date: ______
1 Frank W. Shagets M.D.
2 2700 McClelland Blvd. Ste. 204
3 Joplin, Missouri 64804
4 ( 417) 623 - 5111
5
6 BUSINESS ASSOCIATE CONTRACT
7 This Business Associate Contract (“Contract”), effective ______, 200__ is
8 entered into by and between Frank W. Shagets M.D., with an address at 2700
9 McClelland Blvd. Suite 204Joplin, Missouri64804 and ______
10 (the“Contractor”), with an address at ______11 (each a “Party” and collectively the “Parties”).
12
13
14 WITNESSETH:
15
16 WHEREAS, the U.S. Department of Health and Human Services (“HHS”) has issued
17 final regulations, pursuant to the Health Insurance Portability and Accountability Act of
18 1996 (“HIPAA”), governing the privacy of individually identifiable health information
19 obtained, created or maintained by certain entities, including healthcare providers (the