MEMBER HANDBOOK BUCKS, DELAWARE AND MONTGOMERY COUNTIES. for Persons on HealthChoices Medical Assistance

Size: px
Start display at page:

Download "MEMBER HANDBOOK BUCKS, DELAWARE AND MONTGOMERY COUNTIES. for Persons on HealthChoices Medical Assistance"

Transcription

1 MEMBER HANDBOOK BUCKS, DELAWARE AND MONTGOMERY COUNTIES Mental Health, Substance Abuse & Co-Occuring Services for Persons on HealthChoices Medical Assistance MAGELLAN BEHAVIORAL HEALTH of Pennsylvania, Inc. (an affiliate of Magellan Health Services)

2 MAGELLAN YOUR LINK TO BEHAVIORAL HEALTH SERVICES Make sure you always have your information available by completing the section below: Name: Member ID Number: Primary Care Physician Name: Phone Number: Physical Health/HMO Name: Phone Number: Pharmacy Name: Location: Phone Number: Provider Name: Phone Number: Provider Name: Phone Number: Si desea una edición en español, por favor llame a la línea para miembros del condado de Bucks , Delaware , Montgomery

3 WELCOME TO THE HEALTHCHOICES BEHAVIORAL HEALTH PROGRAM Bucks, Delaware and Montgomery Counties and Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) have joined together to provide a behavioral health care program. This program is for people in Bucks, Delaware and Montgomery Counties who are enrolled in the HealthChoices Program and who need help with mental health, substance abuse or co-occurring issues. When you have mental health and substance abuse issues present at the same time, they are called co-occurring. If you have a problem with your physical health, like an infection or a broken arm, you should call your Health Maintenance Organization (HMO). Your HMO will make sure you get care for your physical health needs. No matter which HMO you pick for your physical health, you will use Magellan to get your mental health, substance abuse and co-occurring services. This handbook will tell you about Magellan and how to access services. We are here to help you get the mental health, substance abuse and co-occurring treatment you may need. We will help you find a doctor or counselor for issues such as depression or alcoholism. To get mental health, substance abuse or co-occurring services, or to ask a question or share a concern, call us toll-free at: Bucks County Delaware County Montgomery County For TTY users, call us between 8:30 a.m. and 7 p.m. toll-free at: Bucks County Delaware County Montgomery County For TTY users between 7 p.m. and 8:30 a.m., call us toll-free at: You can reach us from any phone. We are available 24 hours a day, seven days a week to help you get the care you need. When you call our toll-free number, we can provide an interpreter for non- English speaking individuals. 2

4 Table of Contents GETTING HELP... 8 THE MAGELLAN PROVIDER NETWORK... 9 IF YOU HAVE OTHER INSURANCE RECOVERY AND RESILIENCY COVERED SERVICES WHAT TO DO IN AN EMERGENCY OUT-OF-TOWN EMERGENCY CARE IF YOU HAVE SPECIAL NEEDS TRANSPORTATION CONFIDENTIALITY PRIVACY PRACTICES PRESCRIPTION DRUGS WHAT TO DO IF YOU ARE ALREADY IN TREATMENT IF YOU ARE MOVING OUT OF YOUR COUNTY IF YOU CHANGE ADDRESSES WITHIN YOUR COUNTY CHILD AND ADOLESCENT SERVICES ADULT SERVICES YOUR RIGHTS AND RESPONSIBILITES FRAUD, WASTE AND ABUSE MENTAL HEALTH ADVANCE DIRECTIVES COMPLAINTS GRIEVANCES COORDINATING YOUR PHYSICAL HEALTH AND BEHAVIORAL HEALTH CARE INFORMATION ON DOMESTIC VIOLENCE SMOKING CESSATION INFORMATION ON SMOKING AND PREGNANCY CONSUMER SATISFACTION WHO CAN YOU CALL FOR HELP? LIST OF DEFINITIONS

5 Bucks County IMPORTANT TELEPHONE NUMBERS AND WEBSITES Crisis Intervention Services Access Child/Adolescent Mobile Crisis Services HELP-709 ( ) Lenape Valley Foundation Crisis Center Bristol Lenape Valley Foundation Crisis Center Doylestown Penn Foundation Crisis Center at Grand View Hospital Delaware County Crozer-Chester Medical Center Crisis Intervention Mercy Fitzgerald Hospital Crisis Intervention Project Reach Mobile Crisis Services Montgomery County Access Child/Adolescent Mobile Crisis Services HELP-414 ( ) Montgomery County Emergency Services (MCES)

6 County Assistance Offices Bucks County Assistance Office 1214 New Rodgers Road Bristol, PA Toll-free in Pennsylvania: Delaware County Assistance Offices Chester Office 701 Crosby Street Chester, PA Darby Office 845 Main Street Darby, PA Montgomery County District Assistance Offices Norristown District 1931 New Hope Street Norristown, PA Toll-free: FAX: LIHEAP: Pottstown District 24 Robinson Street Pottstown, PA Toll-free: FAX: LIHEAP: Pennsylvania Enrollment Services Consumer Support Center

7 County Offices of Behavioral Health Bucks County Behavioral Health System 600 Louis Drive, Suite 102A Warminster, PA Delaware County Office of Behavioral Health 20 South 69 th Street 3 rd Floor Upper Darby, PA Montgomery County Office of Behavioral Health and Developmental Disabilities Human Services Center 1430 DeKalb St., P.O. Box 311 Norristown, PA Other Important Websites Magellan Website: Department of Public Welfare Website: Office of Mental Health & Substance Abuse Services, PA Recovery and Resiliency Website: 6

8 YOUR PHYSICAL HEALTH CARE Remember, Physical Care Services are accessed through your HMO. HMO names, phone numbers and websites are listed below. TTY lines are for hearing impaired members. Each Physical HMO plan has a Special Needs Unit (SNU) to assist with physical health issues that may impact your behavioral health. You can contact your HMO by calling the 800 number below. Ask to speak to a Special Needs Coordinator. Coventry Cares Health Plan Member Line Coventry Cares Health Plan Special Needs Line Coventry Cares Health Plan TDD Member Line Coventry Cares Health Plan Website Health Partners Member Line Health Partners Special Needs Unit Health Partners TDD Member Line Health Partners Website Keystone Mercy Member Line Keystone Mercy Special Needs Unit Keystone Mercy TDD Member Line Keystone Mercy Website UnitedHealthcare Community Plan Member Line UnitedHealthcare Community Plan Special Needs Unit UnitedHealthcare Community Plan TDD Member Line UnitedHealthcare Community Plan Website Aetna Better Health Member Line Aetna Better Health TDD Member Line Aetna Better Health Website 7

9 GETTING HELP Call Magellan toll-free at: Bucks County Delaware County Montgomery County For TTY users, call us between 8:30 a.m. and 7 p.m. toll-free at: Bucks County Delaware County Montgomery For TTY users between 7 p.m. and 8:30 a.m., call us toll-free at: We are open 24 hours a day, seven days a week to take your calls. Call us at any time when you have questions about your mental health, substance abuse or co-occurring services. If you speak a language other than English, Magellan has staff and providers who speak languages other than English who can help you. We can also assist you with interpreter services. 8

10 THE MAGELLAN PROVIDER NETWORK When you call us, our Customer Service Department will give you addresses and telephone numbers for providers who are located in your area and can best help you with your specific needs. We can help you choose a provider close to where you live if you like. You can also refer to a complete listing of our providers including those who speak languages other than English. This listing is available with this handbook or online at Magellan will make every effort to honor your request for a specific network provider. However, this may not always be possible. Some of the reasons we may not be able to offer you an appointment with your first choice provider include: The provider you chose does not specialize in the area of assistance you need. The provider you chose may not be accepting new members or may not have appointments available. The provider you chose may not feel he or she is the most appropriate provider to best help you with your particular needs. Providers may leave and new providers join our network all the time. You may want to call Magellan to check if a particular provider is currently in our network or look on our website at We can also tell you if the provider is currently accepting new members. We will let you know if your provider leaves our network. You can continue to receive covered services from that provider for 60 days from the date we notify you. If you are already in treatment under another health plan when you enroll in Magellan s program, ask your provider if he or she is in the Magellan HealthChoices network. If the answer is yes, let your provider know that you have changed plans. If the answer is no, call Magellan. You can continue to receive care from your current provider for a transitional period of up to 60 days from the date of your enrollment with Magellan. During this time, we will work with you to transition to an in-network provider. There may be times when you feel you need to see a provider who is not in our network. If we do not have a provider within our network who is qualified to handle your particular needs, it may be possible for Magellan to arrange an out-of-network provider for you. All out-of-network providers 9

11 must have prior authorization by Magellan before you can see them in order for your visit to be covered. Please call our Customer Service Department if you feel you need to see an out-of-network provider. You have the right to request a second opinion from a network provider at no cost to you. If a qualified health care professional is not available within the network, Magellan will help you arrange for a second opinion with an out-ofnetwork provider at no cost to you. All out-of-network referrals must have prior authorization from Magellan. Our provider offices are able to help you even if you have a physical disability, such as a problem walking, or trouble seeing or hearing. Please call us if you need to make sure a provider s office is wheelchair accessible or for any other special needs you might have. Magellan and our providers strive to provide quality services to lesbian, gay, bisexual, transgender, questioning and intersex (LGBTQI) individuals. Magellan or our providers cannot discriminate against any individual receiving services regardless of race, ethnicity, actual or perceived sexual orientation, gender identity and/or gender expression. IF YOU HAVE OTHER INSURANCE Magellan/HealthChoices is the last payer of your bill when you have other insurance. That means if you have Medicare or commercial insurance (such as Blue Cross/Blue Shield), you must use that coverage first. Please be aware that you must go to a provider who accepts your other insurance. If your other insurance is Medicare, you must use Medicare first, unless Medicare does not cover the service you need. If you get services from a provider who accepts both your Medicare coverage and Magellan/HealthChoices, show both of your cards so the provider may submit the claim to Medicare and, if necessary, to Magellan/HealthChoices. If your other insurance is a commercial health plan, you must use that plan first, unless your plan does not cover the service you need. If you get services from a provider who accepts both your commercial plan and Magellan/HealthChoices, show both of your cards so the provider may submit the claim to the commercial plan and, if necessary, to Magellan/HealthChoices. 10

12 RECOVERY AND RESILIENCY Magellan fully supports the concepts and principles of Recovery and Resiliency. Recovery is a way of living a satisfying and hopeful life. Recovery involves developing new meaning and purpose in life, even if you have symptoms of mental illness. A few examples of recovery principles are: Hope. Choice. Empowerment. Education. Resiliency is the ability to bounce back from difficult experiences, or to do well in spite of hard times. Generally, people who are resilient: Are supportive. Are positive and optimistic. Have good problem solving skills. Have good social skills. Are involved in their communities. Have good self-esteem. Make use of available supports to maintain recovery. You should expect that the services you receive from our network providers are focused on both recovery and resiliency. COVERED SERVICES This managed care plan may not cover all your health care expenses. Read your handbook carefully to determine which health care services are covered. Magellan covers only the behavioral health care services described in this member handbook. We do offer some supplemental services developed with each county that may not be listed in this handbook. All services must meet medical necessity criteria and be approved by us. Once services begin, they will continue to be approved as long as they are still recommended by your provider, and medical necessity criteria are met. 11

13 Magellan is here for your behavioral health needs. We offer you a number of different services to best meet your needs. At Magellan, we believe in working with you and your family in your community. Our services are free. You never have to pay for services we arrange for you. The Medical Assistance Program is designed to pay for these services. Your Magellan provider is not allowed to bill you for any of the services approved by us. If a Magellan network provider and Magellan disagree about the medical necessity of the services provided to you, the provider may not bill you for any of those services. Magellan provides the following services in Bucks, Delaware and Montgomery Counties. Please note that additional services called supplemental services may be available in your county. Evaluation, Planning and Coordination of Treatment Needs A counselor or doctor in the Magellan network works together with you to plan your care. Outpatient Psychiatric, Substance Abuse and Co-Occurring Services You meet with a counselor or doctor in the Magellan network in your community on a regular basis. Your counselor or doctor helps you with your mental health, substance abuse or co-occurring needs. Mobile Outpatient Mental Health Services Mental health treatment may be provided in your home in certain situations. Peer Support Services Peer Support Services are services provided by self-identified mental health and/or co-occurring consumers who have successfully completed peer certification training. These services are designed to support recovery and can be delivered in the community, home or office. Smoking Cessation Services Group, individual or online services are provided to help you stop smoking. Medications also may be prescribed by your doctor to help you quit. Partial Hospital Services for Mental Illness, Substance Abuse or Co-Occurring Needs Through partial hospital services, you will work together with your counselor and doctors while living at home. By participating in a program a few hours 12

14 each week as needed, counselors and doctors can help you reach your treatment goals. Community Treatment Team (CTT) and/or Assertive Community Treatment (ACT) CTT and ACT are mobile teams that provide comprehensive and intensive treatment, rehabilitation and support services to individuals with serious and persistent mental illness and co-occurring disorders who have not been able to achieve and maintain stability in the community. Services are provided by a team of behavioral health professionals in your community setting. Non-Hospital Residential Detoxification, Rehabilitation and Halfway House You live, for a period of time, in a treatment facility other than a hospital, which will support your efforts to stop using alcohol and/or drugs. Psychiatric Inpatient Services You receive 24-hour care in a facility for mental health or co-occurring needs. Substance Abuse, Detoxification and Rehabilitation Inpatient Services You receive 24-hour care in a facility for alcohol and/or other drug issues. Crisis Services 24 Hours a Day, Seven Days a Week If you have a behavioral health emergency, a counselor or doctor can see you right away. If it s a life-threatening situation, please call 911 immediately. Medications for Mental Health, Substance Abuse and Co- Occurring Treatment A variety of medications are available, as needed, for the treatment of mental health, substance abuse and co-occurring issues. Methadone is included, if needed, along with support services. Laboratory Services and Clozapine Support Services You may receive testing of blood or urine specimens to determine if a specific medication is working for you. Ongoing support is provided. Case Management Services (Intensive Case Management, Resource Coordination and Blended Case Management) You and/or your child receive help with accessing and coordinating other resources, such as medical, social, housing, educational and other services. 13

15 Behavioral Health Rehabilitation Services for Children and Adolescents (formerly known as EPSDT) Magellan members, from birth to age 21, may be eligible for special services through a program called Behavioral Health Rehabilitation Services for Children and Adolescents (BHRSCA). A doctor, another health care provider or a member can contact Magellan to learn about these services. Family-Based Mental Health Services for Children and Adolescents Children, adolescents and their family members receive intensive home therapy, case management and family support services. Residential Treatment for Children and Adolescents Children and adolescents receive behavioral health treatment for mental health or co-occurring issues while living in a structured setting. Multi-Systemic Therapy (MST) MST is an evidence-based treatment approach for youth between the ages of 11 and 18 with a primary mental health diagnosis involved with, or at risk for involvement with, the juvenile justice system. If Magellan does not provide a treatment service because of moral or religious objections, we do not need to give you information on how and where to obtain these services. The Department of Public Welfare will provide information to you on these services if needed. Magellan may not pay for services that are considered experimental. These include services that are not yet properly tested and/or accepted as standard treatment. Please pay careful attention to the description of your grievance and appeal rights in this booklet. If you appeal a service denial and your appeal is not successful, you may have to pay for services not approved by Magellan if the services were provided by a provider not in Magellan s network. Other Important Information We want you to be fully informed about Magellan and our services. The following is a list of additional information you may request: A list of Magellan s Board of Directors. A copy of our confidentiality procedures. Our criteria for approving providers. Our process for deciding if a service is experimental. 14

16 A description of how providers are paid. A description of our Quality Assurance program. The process by which HealthChoices providers can obtain approval to prescribe a non-formulary medication. WHAT TO DO IN AN EMERGENCY What is an emergency? An emergency is when a person with an average knowledge of health and medicine thinks they must act fast to prevent serious health problems. If you are not sure if your situation is an emergency, call Magellan at: Bucks County Delaware County Montgomery County For TTY users, call us between 8:30 a.m. and 7 p.m. toll-free at: Bucks County Delaware County Montgomery County For TTY users between 7 p.m. and 8:30 a.m., call us toll-free at: You do not have to get prior approval from Magellan to receive emergency services. Act quickly if you or anyone in your family has a behavioral health emergency that you feel is life-threatening or will result in serious damage to you or a family member s health. Call 911 and tell the operator where you are located and what the emergency is, or go immediately to the nearest emergency room. If emergency transportation such as an ambulance is needed, the 911 operator will send an ambulance to your location. Please note that you can use ANY hospital or emergency service for emergency care. Below are the psychiatric emergency service locations: 15

17 Bucks County Lenape Valley Foundation Crisis Center Lower Bucks Hospital 501 Bath Road Bristol, PA Lenape Valley Foundation Crisis Center Doylestown Hospital 500 North West Street Doylestown, PA Penn Foundation at Grand View Hospital Emergency Room 700 Lawn Avenue Sellersville, PA Access Mobile Crisis Services for Children and Adolescents HELP-709 ( ) Delaware County Crozer-Chester Medical Center 1 Medical Center Blvd. Chester, PA Mercy Fitzgerald Hospital 1500 Lansdowne Avenue Darby, PA Project Reach Mobile Crisis Services

18 Montgomery County Children s Crisis Support System (Mobile Crisis) HELP- 414 ( ) Montgomery County Emergency Services (MCES)* 50 Beech Drive Norristown, PA *Please note that MCES is primarily for adults. When seeking care for young adults and children, families are encouraged to consider other alternatives specializing in young adults and children. Please contact Magellan to get options at Emergency Care Services May Include: Evaluation and counseling. Psychiatric evaluation. Drug and/or alcohol detoxification. Hospitalization. If you need follow-up care after an emergency, call Magellan. We will help you get an appointment with a provider. Magellan will notify you at least 30 days before the effective date of any changes to procedures related to emergency services. OUT-OF-TOWN EMERGENCY CARE Your treatment is covered if you have a behavioral health emergency while you are traveling. We will pay for authorized services if you have to go into a hospital for a behavioral health emergency. Tell the hospital that you are a Magellan member and provide the name of the county where you live. Ask the hospital to call Magellan s toll-free customer services phone number: Bucks County Delaware County Montgomery County

19 If you cannot contact Magellan right away, try to call us within 24 hours or as soon as possible. If you need additional care, Magellan must approve it first. IF YOU HAVE SPECIAL NEEDS Magellan wants to know if you have special needs for behavioral health services, for example: If you have a serious mental illness. If you are a pregnant woman who is using substances or intravenous drugs. If you have a chronic medical condition such as HIV/AIDS, diabetes or heart disease. If you have an intellectual disability. If you are an adult aged 60 and over. Our staff works with other agencies, such as your HMO, your county s Department of Mental Health and Office of Intellectual/Developmental Disability, the Area Agency on Aging and the Children & Youth Social Service Agency, to help organize treatment and support. When seeking behavioral health services, let us know about your special needs so that we can help you get the best care. Call us at: Bucks County Delaware County Montgomery County For TTY users, call us between 8:30 a.m. and 7 p.m. toll-free at: Bucks County Delaware County Montgomery County For TTY users between 7 p.m. and 8:30 a.m., call us toll-free at TRANSPORTATION If you have difficulty getting to an appointment with a provider, call Magellan. We will help you get a ride by giving you information about county transportation services. Or, you can reach your local county 18

20 transportation services at: Bucks County Transport (Local) (Toll-free) Delaware County Transport (Local) (TDD) Montgomery County Transport CONFIDENTIALITY Magellan is serious about protecting your privacy. We follow all state and federal laws. The only people who have access to information about you are Magellan staff and certain government representatives who monitor quality and delivery of services. Generally, we do not give out any information about your treatment to anyone else without your written permission. One exception is if there is a lifethreatening emergency. Then certain information may be shared in order to be sure that people are safe. Another is that information may be disclosed as required by law, such as pursuant to a court order or valid subpoena. Finally, we may share information with county, state and federal agencies involved in the HealthChoices Program. PRIVACY PRACTICES This information describes how medical information about you may be used and disclosed and how you can get access to this information. Uses and Disclosures of Protected Health Information Your Protected Health Information ( PHI ) is any information related to your health or treatment that also identifies you. We believe in keeping your health information private. We can only use or disclose your health information for certain reasons. The types of uses and disclosures are listed and explained below. Note that an example is not listed for every use or disclosure reason. We will use the least amount of information necessary when giving or using 19

21 your information. We may need to use or disclose information in a way that is not listed in this notice. If so, we will ask for your written OK before we use or disclose your information. Types of Uses or Disclosures of Information Payment We may use and disclose your health information for payment activities. An example is we may have to share information with another health plan. We will do this to find out who is responsible for paying for your care. Treatment We may use your health information to assist in providing treatment or services. Treatment means the provision, coordination or management of your health care. An example of this is that we may use the information you give us when conducting an assessment or providing clinical consultation. Health Care Operations We use your information to run our program and to make sure that you get quality care. We may use your information for the following: Quality assurance. Case management and coordination of health care. Contacting you and your providers with information about other forms of treatment. Activities to look at trends to improve and lower the cost of health care. A look at how often you use your treatment. This includes review by companies not connected with Magellan. This is done when you or your provider requests the review. For example, to make sure you are getting the right kind of care, our care managers look at your health information. This helps them to know if the kind of care your provider asks for is medically necessary. It also helps them to decide if care requested is the right kind to treat your condition. Health Oversight Activities We may share your information with health oversight agencies. We do this for activities authorized by law. These activities are needed for the government to oversee the following: Health care systems. Compliance of government benefit programs. 20

22 Compliance with civil rights laws. Disclosures may happen through one or more of the following: o o o o Audits. Investigations. Licensure or disciplinary actions. Civil, administrative or criminal proceedings. We will provide the least amount of information required by law. Disclosures to the County and the State We may disclose your health information to your county and/or to the state. We will do this once we have their written assurance. This assurance will make sure that it will be used correctly. They must follow the HIPAA Privacy regulation guidelines. Only the least amount of information will be disclosed. Information Relating to the Treatment of Minors We will follow state and federal laws for keeping information regarding the treatment of minors private. Many states allow minors to get treatment without an OK from their parents. They do this for minors who are of a certain age. We follow all laws that apply to the confidentiality of treatment for minors. Health-Related Benefits or Services We may use or disclose your health care information for preventive treatment reasons. For example, a family who has a child with attention deficit disorder may be mailed a notice. This notice will tell parents about services available to screen other children in the family for attention deficit disorder. Lawsuits and Disputes We share your information with the court when the law says we can or we must. For example, a court might order us to provide your information. Appointment Reminders We may use or disclose your health information to remind you about an appointment for treatment or medical care. Treatment Alternatives There are other types of treatment that may interest you. We may use or disclose your health information to let you know about them. The ways in 21

23 which we use your information are handled in a manner that protects your privacy. Disclosure of Information to Family Members We may give a limited amount of your information to someone involved in your care in an emergency or if you cannot give us an OK. We will only give them the information connected to their involvement in your care. Disclosure of Information to the Armed Forces We will disclose your health information to the armed forces if you are or were a member of the armed forces, as required by law. We will disclose the least amount of information needed to carry out the purpose of the release. To Comply with Workers Compensation We will not give out your health information to workers compensation programs without your permission. As Required or Permitted by Law for Public Safety If we have to or are permitted to by law, we will disclose your health information for public safety. A disclosure may be made to protect you from serious danger to your health or safety. It can also be made to protect the health or safety of another person. We will release just the amount of information needed to follow the law. Government Security Clearances We may share your information where required by law for government security clearances. We will release just the amount of information needed for the clearance. Public Health Risks We may share your information for public health reasons. For example, if necessary we may share your information to report child abuse or neglect. Inmates If you are an inmate or in the custody of law enforcement, we may disclose your health information without your permission. We will do this for your health care. We will also do this for the care and safety of others. We may also release it to the facility where you are being held for further law enforcement or safety reasons. 22

Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995

Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995 Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY

More information

Patients First: How We Protect Your Privacy

Patients First: How We Protect Your Privacy Patients First: How We Protect Your Privacy To Our Patients: At Northwestern Memorial Hospital, we are committed to providing you with the highest quality of care in an environment that protects your privacy

More information

Floyd Healthcare Management, Inc. Notice of Privacy Practices

Floyd Healthcare Management, Inc. Notice of Privacy Practices Floyd Healthcare Management, Inc. 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

More information

Bucks County Drug & Alcohol Commission, Inc.

Bucks County Drug & Alcohol Commission, Inc. Bucks County Drug & Alcohol Commission, Inc. 600 Louis Drive Diane W. Rosati, MA Suite 102A Executive Director Warminster, PA 18974 Fax (215) 956-9939 (215) 773-9313, Option 2, Ext. 2703 dwrosati@co.bucks.pa.us

More information

PATIENT INTAKE FORM PATIENT INFORMATION. Name Soc. Sec. # Last Name First Name Initial Address. City State Zip. Home Phone Work/Mobile Phone

PATIENT INTAKE FORM PATIENT INFORMATION. Name Soc. Sec. # Last Name First Name Initial Address. City State Zip. Home Phone Work/Mobile Phone PATIENT INTAKE FORM PATIENT INFORMATION Name Soc. Sec. # Last Name First Name Initial Address City State Zip Home Phone Work/Mobile Phone Sex M F Age Birth date Single Married Widowed Separated Divorced

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE OF PRIVACY PRACTICES

More information

Health Partners Plans Provider Manual 14 Appendix

Health Partners Plans Provider Manual 14 Appendix Health Partners Plans Provider Manual 14 Appendix Topics: HPP Participating Hospitals DHS Domestic Violence Initiatives DHS Fraud and Abuse Hotline Member Rights & Responsibilities Preventive Care Guidelines/EPSDT

More information

NORTHSTAR DERMATOLOGY, PA NOTICE OF PRIVACY PRACTICES

NORTHSTAR DERMATOLOGY, PA NOTICE OF PRIVACY PRACTICES NORTHSTAR DERMATOLOGY, PA 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

More information

If you have any questions about this notice, please contact Mimi McNichol 215-985-4448 ext. 223.

If you have any questions about this notice, please contact Mimi McNichol 215-985-4448 ext. 223. Philadelphia FIGHT NOTICE OF PRIVACY PRACTICES. Effective Date: April 14, 2003 Last Revised: May 2014 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET

More information

Harris County - Texas HIPAA Notice of Privacy Practices

Harris County - Texas HIPAA Notice of Privacy Practices Harris County - Texas HIPAA Notice of Privacy Practices Effective Date: September 23, 2013. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

HIPAA Privacy Notice

HIPAA Privacy Notice HIPAA Privacy Notice 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. This notice describes

More information

Virginia South Psychiatric & Family Services

Virginia South Psychiatric & Family Services All forms must be completed before seeing the Physician Information for Medical Records Patient s Name: Social Security #: Date of Birth: Sex: Male Female Marital Status: Single Married Divorced Widow

More information

HIPAA NOTICE OF PRIVACY PRACTICES

HIPAA NOTICE OF PRIVACY PRACTICES HIPAA NOTICE OF PRIVACY PRACTICES Marden Rehabilitation Associates, Inc. Marden Rehabilitation Associates of Ohio, Inc. Marden Rehabilitation Associates of West Virginia Health Care Plus Preferred Care

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Drug Abuse Prevention, Treatment, and Rehabilitation ACT THE CENTER FOR HEALTH CARE SERVICES 3031 IH

More information

Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record

Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record Welcome to my office! Below is some information you may wish to read before your first appointment. Included

More information

HIPAA PRIVACY NOTICE PLEASE REVIEW IT CAREFULLY

HIPAA PRIVACY NOTICE PLEASE REVIEW IT CAREFULLY HIPAA PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. INTRODUCTION PLEASE REVIEW IT CAREFULLY Moriarty

More information

650 Clark Way Palo Alto, CA 94304 650.326.5530

650 Clark Way Palo Alto, CA 94304 650.326.5530 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. (Adopted 4-14-03; revised December 2006) If

More information

Pharmacy Handbook. Understanding Your Prescription Benefit

Pharmacy Handbook. Understanding Your Prescription Benefit Pharmacy Handbook Understanding Your Prescription Benefit 1 Welcome to Your Prescription Drug Plan! Health Republic Insurance of New York has partnered with US Script to manage your prescription drug benefits.

More information

UAB MY HEALTH REWARDS BIOMETRIC SCREENING PROGRAM NOTICE OF HEALTH INFORMATION PRACTICES

UAB MY HEALTH REWARDS BIOMETRIC SCREENING PROGRAM NOTICE OF HEALTH INFORMATION PRACTICES UAB MY HEALTH REWARDS BIOMETRIC SCREENING PROGRAM NOTICE OF HEALTH INFORMATION PRACTICES 1 Effective Date: January 26, 2015 THIS NOTICE APPLIES TO THE UAB MY HEALTH REWARDS BIOMETRIC SCREENING PROGRAM

More information

Notice of Privacy Practices

Notice of Privacy Practices 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. About this notice

More information

SOUTHLAKE DERMATOLOGY 1170 N. Carroll Ave. Southlake, TX 76092 www.southlakedermatology.com Main 817-251-6500 Fax 817-442-0550

SOUTHLAKE DERMATOLOGY 1170 N. Carroll Ave. Southlake, TX 76092 www.southlakedermatology.com Main 817-251-6500 Fax 817-442-0550 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. EFFECTIVE September 15, 2014 This Notice of

More information

APPLETREE PEDIATRICS, PA NOTICE OF PRIVACY PRACTICES

APPLETREE PEDIATRICS, PA NOTICE OF PRIVACY PRACTICES APPLETREE PEDIATRICS, PA 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.

More information

HIGHMARK BLUE CROSS BLUE SHIELD DELAWARE NOTICE OF PRIVACY PRACTICES PART I NOTICE OF PRIVACY PRACTICES (HIPAA)

HIGHMARK BLUE CROSS BLUE SHIELD DELAWARE NOTICE OF PRIVACY PRACTICES PART I NOTICE OF PRIVACY PRACTICES (HIPAA) Sí necesita ayuda para traducir esta información, por favor comuníquese con el departamento de Servicios a miembros de Highmark Delaware al número al réves de su tarjeta de identificación de Highmark Delaware.

More information

The Health and Benefit Trust Fund of the International Union of Operating Engineers Local Union No. 94-94A-94B, AFL-CIO. Notice of Privacy Practices

The Health and Benefit Trust Fund of the International Union of Operating Engineers Local Union No. 94-94A-94B, AFL-CIO. Notice of Privacy Practices The Health and Benefit Trust Fund of the International Union of Operating Section 1: Purpose of This Notice Notice of Privacy Practices Effective as of September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL

More information

Polk Medical Center Notice of Privacy Practices

Polk Medical Center Notice of Privacy Practices Polk Medical Center 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.

More information

Population Health Management Program Notice of Privacy Practices from Evolent Health

Population Health Management Program Notice of Privacy Practices from Evolent Health Population Health Management Program Notice of Privacy Practices from Evolent Health MedStar Health, Inc., a Maryland not-for-profit corporation, has contracted with Evolent Health, Inc., a Delaware corporation

More information

Effective April 14, 2003

Effective April 14, 2003 Effective April 14, 2003 THE BOEING COMPANY GROUP HEALTH PLANS NOTICE OF PRIVACY PRACTICES This notice describes how health plan medical information about you may be used and disclosed and how you can

More information

SDC-League Health Fund

SDC-League Health Fund SDC-League Health Fund 1501 Broadway, 17 th Floor New York, NY 10036 Tel: 212-869-8129 Fax: 212-302-6195 E-mail: health@sdcweb.org NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION

More information

Salt Lake Community College Employee Health Care Benefits Plan Notice of Privacy Practices

Salt Lake Community College Employee Health Care Benefits Plan Notice of Privacy Practices THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Date: June 1, 2014 Salt Lake Community College

More information

NOTICE OF PRIVACY PRACTICES. The University of North Carolina at Chapel Hill. UNC-CH School of Nursing Faculty Practice Carolina Nursing Associates

NOTICE OF PRIVACY PRACTICES. The University of North Carolina at Chapel Hill. UNC-CH School of Nursing Faculty Practice Carolina Nursing Associates NOTICE OF PRIVACY PRACTICES The University of North Carolina at Chapel Hill UNC-CH School of Nursing Faculty Practice Carolina Nursing Associates THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU

More information

Welcome To Our Physical Therapy Department

Welcome To Our Physical Therapy Department Welcome To Our Physical Therapy Department Our entire staff is dedicated to providing our patients with the best possible care and service while keeping the costs to you from increasing at an unreasonable

More information

The Healthy Michigan Plan Handbook

The Healthy Michigan Plan Handbook The Healthy Michigan Plan Handbook Introduction The Healthy Michigan Plan is a health care program through the Michigan Department of Community Health (MDCH). The Healthy Michigan Plan provides health

More information

NOTICE OF PRIVACY PRACTICE UCLA COUNSELING AND PSYCHOLOGICAL SERVICES (CAPS)

NOTICE OF PRIVACY PRACTICE UCLA COUNSELING AND PSYCHOLOGICAL SERVICES (CAPS) Effective Date: September 23, 2013 NOTICE OF PRIVACY PRACTICE UCLA COUNSELING AND PSYCHOLOGICAL SERVICES (CAPS) THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices (Effective date: May 1, 2008) This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES 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. Important Notice

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices Effective September 20, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

More information

NOTICE OF PRIVACY PRACTICE

NOTICE OF PRIVACY PRACTICE Effective Date: September 23, 2013 NOTICE OF PRIVACY PRACTICE UNIVERSITY OF CALIFORNIA SAN FRANCISCO UCSF HEALTH SYSTEM THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

More information

WASHINGTON HOSPITAL HEALTHCARE SYSTEM (WHHS) NOTICE OF PRIVACY PRACTICES

WASHINGTON HOSPITAL HEALTHCARE SYSTEM (WHHS) NOTICE OF PRIVACY PRACTICES WASHINGTON HOSPITAL HEALTHCARE SYSTEM (WHHS) NOTICE OF PRIVACY PRACTICES Effective Date 8-1-2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

Birkam Health Center Ferris State University NOTICE OF PRIVACY PRACTICES

Birkam Health Center Ferris State University NOTICE OF PRIVACY PRACTICES Birkam Health Center Ferris State University NOTICE OF PRIVACY PRACTICES Effective Date of Notice: October 1, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND

More information

The Healthy Michigan Plan Handbook

The Healthy Michigan Plan Handbook The Healthy Michigan Plan Handbook Introduction The Healthy Michigan Plan is a health care program through the Michigan Department of Community Health (MDCH). Eligibility for this program will be determined

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES In 1996, the U.S. Congress passed the Health Insurance Portability and Accountability Act (HIPAA). Among others, the Act applies to health care providers and hospitals; it is

More information

DALLAS ALLERGY & ASTHMA CENTER

DALLAS ALLERGY & ASTHMA CENTER DALLAS ALLERGY & ASTHMA CENTER Gary N. Gross, MD Michael E. Ruff, MD 5499 Glen Lakes Dr., Suite 100 Dallas, TX 75231 Dania A. Wierzbicki, MD Phone: (214) 691-1330 Jane Zepeda, PA-C FAX: (214) 691-6405

More information

Schindler Elevator Corporation

Schindler Elevator Corporation -4539 Telephone: (973) 397-6500 Mail Address: P.O. Box 1935 Morristown, NJ 07962-1935 NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU

More information

NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA DAVIS HEALTH SYSTEM

NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA DAVIS HEALTH SYSTEM NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003 UNIVERSITY OF CALIFORNIA DAVIS HEALTH SYSTEM THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN

More information

Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record

Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record Office Policies, Informed Consent for Treatment, and Protecting the Privacy of Your Health Record Welcome to my office! Below is some information you may wish to read before your first appointment. Included

More information

Consumer s Right to Know About Health Plans in Rhode Island

Consumer s Right to Know About Health Plans in Rhode Island Consumer s Right to Know bout Health Plans in Rhode Island BlueCHiP BLUE CROSS & BLUE SHIELD of RHODE ISLND January 1, 2016 Consumer Disclosure Safe and Healthy Lives in Safe and Healthy Communities Consumer

More information

SURGICAL CENTER FOR EXCELLENCE PATIENT INFORMATION

SURGICAL CENTER FOR EXCELLENCE PATIENT INFORMATION As a person with pain, you have the right to: SURGICAL CENTER FOR EXCELLENCE PATIENT INFORMATION PAIN CARE BILL OF RIGHTS Have your report of pain taken seriously and to be treated with dignity and respect

More information

Community Health of South Florida, Inc. 10300 SW 216 th Street Miami, FL 33190. Notice of Privacy Practices

Community Health of South Florida, Inc. 10300 SW 216 th Street Miami, FL 33190. Notice of Privacy Practices Community Health of South Florida, Inc. 10300 SW 216 th Street Miami, FL 33190 Effective Date: April 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN

More information

HIPAA Omnibus Notice of Privacy Practices Effective Date: March 03, 2012 Revised on: July 1, 2015

HIPAA Omnibus Notice of Privacy Practices Effective Date: March 03, 2012 Revised on: July 1, 2015 HIPAA Omnibus Notice of Privacy Practices Effective Date: March 03, 2012 Revised on: July 1, 2015 Mobile Physician Group PC 231 High Street Suite 1, Mount Holly, NJ 08060 1-855-MPG-DOCS THIS NOTICE DESCRIBES

More information

Notice of Privacy Practices

Notice of Privacy Practices 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. Privacy is a very

More information

Population Health Management Program Notice of Privacy Practices

Population Health Management Program Notice of Privacy Practices Population Health Management Program Notice of Privacy Practices Premier Health provides population health management services to its health plan members. Services include wellness program tools and technology,

More information

A A E S C. Albuquerque Ambulatory Eye Surgery Center NOTICE OF PRIVACY PRACTICES

A A E S C. Albuquerque Ambulatory Eye Surgery Center NOTICE OF PRIVACY PRACTICES A A E S C Albuquerque Ambulatory Eye Surgery Center 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.

More information

Garland s Christian Counseling Center

Garland s Christian Counseling Center Garland s Christian Counseling Center : PERSONAL DATA Name: Email: Home Phone: Address: Cell Phone: Work Phone: (Street, City, Zip Code) DL #, ST & Exp : SS#: DOB: Sex: Please circle where we may leave

More information

Consumer s Right to Know About Health Plans in Rhode Island

Consumer s Right to Know About Health Plans in Rhode Island Consumer s Right to Know bout Health Plans in Rhode Island BasicBlue BLUE CROSS & BLUE SHIELD of RHODE ISLND January 1, 2016 Consumer Disclosure Safe and Healthy Lives in Safe and Healthy Communities Consumer

More information

We are required to provide this Notice to you by the Health Insurance Portability and Accountability Act ("HIPAA")

We are required to provide this Notice to you by the Health Insurance Portability and Accountability Act (HIPAA) PRIVACY NOTICE We are required to provide this Notice to you by the Health Insurance Portability and Accountability Act ("HIPAA") THIS NOTICE DESCRIBES HOW PERSONAL AND MEDICAL INFORMATION ABOUT YOU MAY

More information

OUR LADY OF THE LAKE, HOSPITAL INC. AND OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC NOTICE OF PRIVACY PRACTICES

OUR LADY OF THE LAKE, HOSPITAL INC. AND OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC NOTICE OF PRIVACY PRACTICES OUR LADY OF THE LAKE, HOSPITAL INC. AND OUR LADY OF THE LAKE PHYSICIAN GROUP, LLC NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU

More information

Population Health Management Program Notice of Privacy Practices from Piedmont WellStar HealthPlans, Inc.

Population Health Management Program Notice of Privacy Practices from Piedmont WellStar HealthPlans, Inc. Population Health Management Program Notice of Privacy Practices from Piedmont WellStar HealthPlans, Inc. Piedmont WellStar HealthPlans, Inc. (PWHP) provides population health management services to its

More information

Privacy Notice. The Plan s duties with respect to health information about you

Privacy Notice. The Plan s duties with respect to health information about you Privacy Notice Please carefully review this notice. It describes how medical information about you may be used and disclosed and how you can get access to this information. The Health Insurance Portability

More information

Lattimore Physical Therapy and Sports Rehabilitation Network Monroe and Livingston County Clinics NOTICE OF PRIVACY PRACTICES

Lattimore Physical Therapy and Sports Rehabilitation Network Monroe and Livingston County Clinics NOTICE OF PRIVACY PRACTICES Lattimore Physical Therapy and Sports Rehabilitation Network Monroe and Livingston County Clinics NOTICE OF PRIVACY PRACTICES This notice describes the privacy practices of LATTIMORE PHYSICAL THERAPY AND

More information

Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center

Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center Intensive Outpatient Program Participant Handbook Table Of Contents: Welcome..... Page 1 Introduction. Page 1 Staff Page 1 Informed

More information

NOTICE OF HEALTH INFORMATION PRACTICES

NOTICE OF HEALTH INFORMATION PRACTICES NOTICE OF HEALTH INFORMATION PRACTICES Effective Date: April 14, 2003 Date Amended: 9/5/13 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO

More information

NOTICE OF PRIVACY PRACTICES FOR ONSLOW AMBULATORY SERVICES, INC.

NOTICE OF PRIVACY PRACTICES FOR ONSLOW AMBULATORY SERVICES, INC. NOTICE OF PRIVACY PRACTICES FOR ONSLOW AMBULATORY SERVICES, INC. THIS NOTICE DESCRIBES HOW MEDIAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE

More information

LIFESTREAM BEHAVIORAL CENTER, INC. JOINT NOTICE OF PRIVACY PRACTICES. Effective Date: April 14, 2003

LIFESTREAM BEHAVIORAL CENTER, INC. JOINT NOTICE OF PRIVACY PRACTICES. Effective Date: April 14, 2003 LIFESTREAM BEHAVIORAL CENTER, INC. JOINT NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003 THIS DOCUMENT DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET

More information

9129 Monroe Rd. Suite 100, Charlotte, NC 28270

9129 Monroe Rd. Suite 100, Charlotte, NC 28270 9129 Monroe Rd. Suite 100, Charlotte, NC 28270 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

More information

GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM

GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM DATE: CHART#: GUARANTOR INFORMATION LAST NAME: FIRST NAME: MI: ADDRESS: HOME PHONE: ADDRESS: CITY/STATE: ZIP CODE: **************************************************************************************

More information

Effective Date of This Notice: September 1, 2013

Effective Date of This Notice: September 1, 2013 Rev.10-2013-KB P-drive-HR Forms NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED BY United Cerebral Palsy of Miami (UCP) and

More information

NOTICE OF PRIVACY PRACTICES. for Sony Pictures Entertainment Inc.

NOTICE OF PRIVACY PRACTICES. for Sony Pictures Entertainment Inc. NOTICE OF PRIVACY PRACTICES for Sony Pictures Entertainment Inc. [Para recibir esta notificación en español por favor llamar al número proviso en este documento.] This notice describes how medical information

More information

HIPAA Notice of Privacy Practices Effective Date: 09/23/13

HIPAA Notice of Privacy Practices Effective Date: 09/23/13 HIPAA Notice of Privacy Practices Effective Date: 09/23/13 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

More information

Client Rights Handbook. Your rights and responsibilities as a consumer of Access Family Services, Inc.

Client Rights Handbook. Your rights and responsibilities as a consumer of Access Family Services, Inc. Client Rights Handbook Your rights and responsibilities as a consumer of Access Family Services, Inc. Key Contacts Chief Executive Officer 704 521 4977 Chief Operating Officer 704 521 4977 President Southeastern

More information

PRIVACY HIPAA NOTICE OF PRACTICE

PRIVACY HIPAA NOTICE OF PRACTICE PRIVACY HIPAA NOTICE OF PRACTICE Bux-Mont Allergy & Asthma, L.L.C. NOTICE OF PRIVACY PRACTICES Effective date: September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND

More information

Connecticut Carpenters Health Fund Privacy Notice

Connecticut Carpenters Health Fund Privacy Notice Connecticut Carpenters Health Fund Privacy Notice 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.

More information

HIPAA Privacy Policies

HIPAA Privacy Policies HIPAA Privacy Policies Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA) The HIPAA Privacy Rule created a national standard to protect patient s medical records and other personal

More information

Policy & Procedure AUTUMN RIDGE RESIDENTIAL CARE. March, 2013

Policy & Procedure AUTUMN RIDGE RESIDENTIAL CARE. March, 2013 AUTUMN RIDGE RESIDENTIAL CARE Policy & Procedure HIPAA / PRIVACY NOTICE OF PRIVACY PRACTICES FUNCTION NUMBER PRIOR ISSUE EFFECTIVE DATE March, 2013 PURPOSE To ensure that a Notice of Privacy Practices

More information

Northern Illinois Health Insurance Program HIPAA NOTICE OF PRIVACY PRACTICES PLEASE READ CAREFULLY

Northern Illinois Health Insurance Program HIPAA NOTICE OF PRIVACY PRACTICES PLEASE READ CAREFULLY Northern Illinois Health Insurance Program HIPAA NOTICE OF PRIVACY PRACTICES PLEASE READ CAREFULLY This notice describes how medical information about you may be used and disclosed and how you can get

More information

Performance Standards

Performance Standards Performance Standards Co-Occurring Disorder Competency Performance Standards are intended to provide a foundation and serve as a tool to promote continuous quality improvement and progression toward best

More information

University HealthCare Alliance

University HealthCare Alliance NOTICE OF PRIVACY PRACTICES University HealthCare Alliance Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY.

More information

Requirements For Provider Type 11 Mental Health/Substance Abuse Services

Requirements For Provider Type 11 Mental Health/Substance Abuse Services Requirements For Provider Type 11 Mental Health/Substance Abuse Services Specialty Code Please choose from the following for specialty and code: 113 - Partial Psychiatric Hospitalization (Children) 114

More information

IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT OUR PRIVACY OFFICER:

IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT OUR PRIVACY OFFICER: NOTICE OF PRIVACY PRACTICES COMPLETE EYE CARE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

JOINT NOTICE OF PRIVACY PRACTICES Cumberland County Hospital System d/b/a Cape Fear Valley Health System

JOINT NOTICE OF PRIVACY PRACTICES Cumberland County Hospital System d/b/a Cape Fear Valley Health System JOINT NOTICE OF PRIVACY PRACTICES Cumberland County Hospital System d/b/a Cape Fear Valley Health System EFFECTIVE: September 23, 2013 THIS JOINT NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT

More information

WELCOME TO STRAITH HOSPITAL FOR SPECIAL SURGERY OUR PHILOSOPHY JOINT NOTICE OF PRIVACY PRACTICES

WELCOME TO STRAITH HOSPITAL FOR SPECIAL SURGERY OUR PHILOSOPHY JOINT NOTICE OF PRIVACY PRACTICES WELCOME TO STRAITH HOSPITAL FOR SPECIAL SURGERY During your stay with us, our goal is to make your hospital experience as favorable as possible by providing information and open channels of communication.

More information

MILITARY HEALTH SYSTEM NOTICE OF PRIVACY PRACTICES. Effective April 14, 2003

MILITARY HEALTH SYSTEM NOTICE OF PRIVACY PRACTICES. Effective April 14, 2003 HEALTH AFFAIRS MILITARY HEALTH SYSTEM NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO

More information

The Family Counseling Center of Fulton County NOTICE OF PRIVACY PRACTICES

The Family Counseling Center of Fulton County NOTICE OF PRIVACY PRACTICES The Family Counseling Center of Fulton County NOTICE OF PRIVACY PRACTICES This notice describes the privacy practices of The Family Counseling Center of Fulton County and the privacy rights of the people

More information

NOTICE OF PRIVACY PRACTICES Allergy Treatment Center of New Jersey, P.C. Effective Date: April 14, 2003

NOTICE OF PRIVACY PRACTICES Allergy Treatment Center of New Jersey, P.C. Effective Date: April 14, 2003 Allergy Treatment Center of New Jersey, P.C. 388 Pompton Avenue 415 Avenel Street Cedar Grove, NJ 07009 Avenel, NJ 07001 (973) 857 9890 (732) 636-7030 NOTICE OF PRIVACY PRACTICES Allergy Treatment Center

More information

PRIVACY POLICY (IN ACCORDANCE WITH HIPAA)

PRIVACY POLICY (IN ACCORDANCE WITH HIPAA) PRIVACY POLICY (IN ACCORDANCE WITH HIPAA) The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. This

More information

NOTICE OF PRIVACY PRACTICES TEMPLATE. Sections highlighted in yellow are optional sections, depending on if applicable

NOTICE OF PRIVACY PRACTICES TEMPLATE. Sections highlighted in yellow are optional sections, depending on if applicable NOTICE OF PRIVACY PRACTICES TEMPLATE Sections highlighted in yellow are optional sections, depending on if applicable Original Date: ##/##/#### Revised per HIPAA Omnibus Rule ##/##/#### Revised Date Implementation:

More information

KAISER PERMANENTE SOUTHERN CALIFORNIA REGION

KAISER PERMANENTE SOUTHERN CALIFORNIA REGION Notice of Privacy Practices KAISER PERMANENTE SOUTHERN CALIFORNIA REGION THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

More information

Anxiety Treatment Center, LLC

Anxiety Treatment Center, LLC Anxiety Treatment Center, LLC 6 Forest Park Drive, 2 nd Floor 860 269 7813 Patient Information Sheet Name: Address: Phone (h) : Phone (w) : Phone (c) : Email: DOB: Family Members (Name, Age, Gender, Relationship)

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices Pueblo Radiology Medical Group, Inc. Pueblo Radiology Associates, Inc. Central Coast Radiology Associates, Inc. Santa Barbara Women s Imaging Center Effective Date: September

More information

Notice of Privacy Practices

Notice of Privacy Practices SHANNON LERACH, Ph.D. Licensed Clinical Psychologist PSY23705 243 N. Highway 101, Suite 16, Solana Beach, CA 92075 Telephone: (619) 817.5320 Fax: (858) 481.1674 Notice of Privacy Practices This Notice

More information

WHERE TO GO FOR HELP DELAWARE COUNTY

WHERE TO GO FOR HELP DELAWARE COUNTY DELAWARE COUNTY WHERE TO GO FOR HELP A Guide to Outpatient Behavioral Health Services for Delaware County s Children and Adolescents Enrolled in Medical Assistance and CHIP A PUBLICATION OF: Public Citizens

More information

Member Handbook and Evidence of Coverage

Member Handbook and Evidence of Coverage 2016 www.hpsm.org Medi-Cal Member Handbook and Evidence of Coverage Last Updated 11/10/ 2015 Last Updated 11/10/ 2015 Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU

More information

The Plan s duties with respect to health information about you

The Plan s duties with respect to health information about you Privacy Notice 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. The Health Insurance Portability

More information

Keeps a physician up to date on all laws and regulations affecting medical practice.

Keeps a physician up to date on all laws and regulations affecting medical practice. Dear Doctor: Thank you for the inquiry you made to the Cooperative of American Physicians, Inc. (CAP). The accompanying document that addresses your professional liability question is published by the

More information

MAIL: Recovery Center Missoula FAX: 406 532 9901 1201 Wyoming St. OR ATTN: Admissions Missoula, MT 59801 ATTN: Admissions

MAIL: Recovery Center Missoula FAX: 406 532 9901 1201 Wyoming St. OR ATTN: Admissions Missoula, MT 59801 ATTN: Admissions Hello and thank you for your interest in Recovery Center Missoula. This letter serves to introduce our program to you, outline eligibility requirements, and describe the application/admission process.

More information

NOTICE OF PRIVACY PRACTICES (NPP)

NOTICE OF PRIVACY PRACTICES (NPP) NOTICE OF PRIVACY PRACTICES (NPP) This Notice contains information about how your medical information may be used and/or disclosed and how you can get access to this information. Please read this Notice

More information