Notice of Privacy Practices

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.

Our Commitment to Your Privacy

We are committed to protecting your health information. We are required by law to maintain the privacy of your protected health information (PHI), to provide you with notice of our legal duties and privacy practices concerning your PHI, and to notify you following a breach of unsecured PHI.

How We May Use and Disclose Your Health Information

We may use and disclose your health information in the following ways:

• Treatment: We may use your health information to provide you with medical care and services. We may also share your information with other healthcare providers involved in your care.
• Payment: We may use and disclose your health information to bill and collect payment for the services we provide to you. This may include providing information to your insurance company, Medicare, Medicaid, or other third parties.
• Healthcare Operations: We may use and disclose your health information for our healthcare operations, including quality assessment, training, accreditation activities, and other business operations.
• As Required by Law: We will disclose your health information when required by federal, state, or local law.
• Public Health Activities: We may disclose your health information for public health activities, including reporting disease and vital statistics.
• Health Oversight Activities: We may disclose your health information to health oversight agencies for activities authorized by law.

Your Rights Regarding Your Health Information

You have the following rights regarding your health information:

• Right to Access: You have the right to inspect and obtain a copy of your health information.
• Right to Amend: You have the right to request an amendment to your health information if you believe it is incorrect or incomplete.
• Right to an Accounting of Disclosures: You have the right to request a list of certain disclosures we have made of your health information.
• Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your health information.
• Right to Request Confidential Communications: You have the right to request that we communicate with you in a certain way or at a certain location.
• Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice upon request.

Changes to This Notice

We reserve the right to change this notice and make the new notice provisions effective for all health information we maintain. If we make a material change to this notice, we will provide a revised notice to you.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, please contact our Privacy Officer. You will not be retaliated against for filing a complaint.

Contact Information

For questions about this notice or to exercise any of your rights, please contact our Privacy Officer at the contact information provided at our facility.

General Consent for Treatment

I, the undersigned patient (or authorized representative of the patient), hereby consent to and authorize the physicians, healthcare providers, and staff of this facility to perform medical treatment, procedures, and services as may be deemed necessary or advisable in the diagnosis and treatment of my condition(s).

Scope of Consent

I understand that this consent includes, but is not limited to:

• Physical examinations and assessments
• Diagnostic procedures and tests (laboratory work, imaging studies, etc.)
• Medical treatments and procedures as recommended by my healthcare providers
• Administration of medications
• Emergency care and treatment when necessary

Understanding of Risks

I acknowledge that the practice of medicine is not an exact science, and I acknowledge that no guarantees have been made to me concerning the results of treatments or examinations. I understand that there are risks associated with any medical treatment or procedure, and that my healthcare providers will discuss specific risks with me before any significant procedures.

Right to Refuse Treatment

I understand that I have the right to refuse any treatment or procedure at any time. I understand that such refusal may have consequences for my health and well-being, and that my healthcare providers will explain these consequences to me.

Release of Information

I authorize the release of my medical information to my insurance company, Medicare, Medicaid, or other third-party payers as necessary for processing claims and receiving payment for services rendered.

Financial Responsibility

I understand that I am financially responsible for all charges not covered by my insurance or other third-party payer. I agree to pay all co-payments, deductibles, and any other amounts due at the time of service or as billed.

Assignment of Benefits

I hereby authorize and direct payment of medical benefits to this healthcare facility for services rendered. I understand that I am financially responsible for any amounts not paid by my insurance.

Patient Rights

I acknowledge that I have been informed of my rights as a patient, including the right to:

• Receive respectful and considerate care
• Privacy and confidentiality of my health information
• Participate in decisions about my care
• Receive information about my diagnosis, treatment, and prognosis
• Refuse treatment and be informed of the consequences
• Review my medical records
• Voice complaints without fear of retaliation