Paperwork

The Health Insurance Portability and Accountability Act (HIPAA)

Your Rights

The following is a statement of your rights with respect to your protected health information:

• You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
• You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purpose of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care, or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restrictions to apply.
• Your physician is not required to agree to a restriction that you may request. If the physician believes it is in your best interest to permit the use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.
• You have the right to request to receive confidential communications from us by alternative means, or at an alternative location. You have the right to obtain a paper copy of this notice from us. Upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.
• You have the right to have your physician amend your protected health information. If we deny your request for an amendment you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal.
• You have the right to receive an accounting of certain disclosures we have made if any of your Protected Health Information.
• We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints: You may complain to us or to the Security of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy policy contact of your complaint. We will not retaliate against you for filing a complaint.

This Notice was published and becomes effective on/or before April 3, 2003. 

We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to Protected Health Information. If you have any objections to this form, please ask to speak to our HIPAA Compliance Officer in person or by phone at our main office telephone number.

The signature below is only an acknowledgment that you have received this Notice of our Privacy Practices.

Patient Consent Form

The Department of Health and Human Services has established a “Privacy Rule” to help ensure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patient’s consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.

As our patients, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.

We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories only interact with physicians, and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.

If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer.

You have the right to review our privacy policy notice, to request restrictions, and revoke consent in writing after you have reviewed our privacy policy notice.

HIPAA Telephone Consent Form

Authorization for Release of Health Information

Financial Policy

Assignment of Benefits and Financial Agreement

Prescription Policy

In an effort to provide our patients with the highest quality care, our practice abides by the following prescription policy. We ask that you carefully read this policy and sign this letter of agreement. By signing this agreement, you are stating that you understand the policy and agree to abide by the policy. This statement is a permanent part of your medical record:

• While a patient of this practice, I shall obtain all controlled substances (if warranted) from the physician at Corinth Medical Specialists only.
• I will not request, nor will I accept any controlled substance medications from any other individual or physician while I am receiving treatment from Corinth Medical Specialists. The only exception is if I become hospitalized or have prior permission from my treating physician.
• I will take the medication as directed, no more and no less. If I use up my medication sooner than prescribed, I understand that it WILL NOT be filled early.
• I am responsible for my controlled substance medication. If the medication is lost, stolen, or disappears for any reason, the medication WILL NOT be replaced.
• Close monitoring of medication dosage is required while being treated with controlled substance medication. Therefore, all scheduled appointments must be kept in order to obtain prescriptions.
• I will be subjected to random drug testing to assure that I am taking my medication.
• I am responsible for keeping track of the amount of my medication and will call with 48 hours (2 days) notification for an appointment or refill if warranted.
• I understand that any deception used to obtain controlled substance prescriptions is a felony, punishable by law, and is grounds for forfeiture of the doctor-patient confidentiality privilege. It is our responsibility to report this type of violation to the appropriate law enforcement authorities.

Any violation of the above guidelines can result in discontinuation of the prescribed medication permanently and/or discharge from Corinth Medical Specialists.

Authorization to Treat Minor Patient Without Parent Consent

Our staff is always concerned for your child’s safety and well-being. Due to this reason, we are requesting your assistance by asking you to fill out the list below. If for some reason you are unable to bring your child to the doctor, please list below all acceptable substitutes who may accompany your child. If it is necessary for someone to bring your child who is not on this list, please call in advance and let us know.

Remember: Only the people who are listed will be able to bring your child.