TERMS AND CONDITIONS
CONSENT FOR ELECTRONIC COMMUNICATION:
We want to communicate with you periodically about your health over text. By accepting the terms and conditions you agree to the following:
I hereby consent and state my preference to have my physician, and other staff communicate with me by SMS, MMS, RCS or other standard text messaging, as well as email, regarding various aspects of my medical care, which may include, but shall not be limited to, test results, prescriptions, appointments, and billing.
I acknowledge that text messaging Valley Women’s Health is no guarantee of an immediate response or may result in no response.
I understand that email and standard SMS messaging are not always a secure method of communication. I further understand that, because of this, there is a risk that email and standard SMS messaging regarding my medical care might be visible by a third party.
I understand that messaging and data rates may apply depending on my plan. I understand that message frequency varies. I understand that I may unsubscribe at any time by replying STOP or clicking the unsubscribe link (where available). I understand that I can reply HELP for help.
I understand that my mobile information will not be sold or shared with third parties for promotional or marketing purposes.
I understand and agree that my Personal Data, including my SMS/MMS opt-in or consent status, may be shared with third parties that help Valley Women’s Health provide messaging services, including but not limited to platform providers, phone companies, and any other vendors who assist in the delivery of text messages.
CONSENT TO TREAT PATIENTS AND RELEASE OF INFORMATION
I authorize care and treatment by Valley Women’s Health and their health care providers. I consent to the use or disclosure of my protected health information for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills, or to conduct health care operations. I understand I have a right to review Valley Women’s Health Notice of Privacy Practices prior to signing this document.
INSURANCE AUTHORIZATION AND TERMS OF ACCOUNT
I understand that Valley Women’s Health will bill my insurance company as a courtesy to me, but I am responsible to see that my account is paid in full. In order to control the cost of billings, we request that the charges for office visits be paid at the conclusion of each visit. There will be a 1.75% interest charge per month (21% APR) for accounts 30 days past due or older. Should any unpaid balance be referred to a collection agency, Utah Code Annotated, sec. 12-1-11, I agree to pay an additional 30% collection fee plus any attorney fees or court costs.
I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance, and other health plans to Valley Women’s Health. I assume responsibility to pay a deductible amount, co-insurance, or any other balance not paid for by my insurance. I understand that I may be charged a co-pay fee if I do not pay my office visit co-pay at the time of service.
I agree and understand that any amount owed is required to be paid within 30 days of receiving the first billing notification. Valley Women’s Health does not send paper statements and the billing Link that is received via Text, Email, or both is my notice of billing. The 30 days will begin from the first notice.
I agree and understand that interest will accrue on all past-due amounts at the rate of 1.75% per month (21% per annum) on balances 30 days past due or older.
I agree and understand that on any unpaid balance that becomes 60 days past due, I will not be able to schedule any further appointments with Valley Women’s Health until my balance is paid in full.
I agree and understand that if I set up Auto-pay payments for my balance that the above is still true, and I will be charged interest monthly at 1.75%, and my account will still be considered past due, and I will be unable to schedule.
If a payment plan is set up, any interest accrued or any new balances outside of what is already included on the payment plan will not automatically be added to the auto payment/ payment plan. We recommend you pay your interest fees monthly in addition to the scheduled payment.
You will still receive monthly notifications of your account status with us, even if you have set up autopay/ payment plan.
As long as your payments are made each month, even if you are in the pre-collections account status, your account will not be sent to collections unless the payments are not made.
I hereby consent to being contacted by Valley Women’s Health at any telephone number including wireless/cellular phone numbers and/or email address) provided by me or anyone associated with me or acting on my behalf. I understand and agree that such calls may be initiated by Valley Women’s Health or any of its affiliate agents, contractors, or assigns, including but not limited to billing companies and/or third-party collection agencies and may include the use of text messages some or all of which may result in data charges. I understand that Valley Women’s Health will inform me of appointments, routine medical results, or changes in scheduling by text and/or email. No detailed information will be disclosed through these methods of communication. If you prefer a different method please let a member of our front office know.
E-PRESCRIBING PBM CONSENT FORM
ePrescribing is defined as a physician’s ability to electronically send an accurate, error free, and understandable prescription directly to a pharmacy. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care.
Benefits data are maintained for health insurance providers by organizations known as Pharmacy Benefits Managers (PBM). PBM’s are third party administrators of prescription drug programs whose primary responsibilities are processing and paying prescription drug claims. They also develop and maintain formularies, which are lists of dispensable drugs covered by a particular drug benefit plan.
The Medicare Modernization Act (MMA) 2003 listed standards that have to be included in an ePrescribe program. These include:
- Formulary and benefit transactions–Gives the prescriber information about which drugs are covered by the drug benefit plan.
- Medication history transactions–Provides the physician with information about medications the patient is already taking prescribed by any provider, to minimize the number of adverse drug events.
By signing this consent form you are agreeing that Valley Women’s Health can request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes.
PERMISSION TO SHARE IMMUNIZATION INFORMATION
The Utah Department of Health maintains a voluntary, confidential record system for you, and your health care providers in documenting your immunizations. This record system is called the Utah Statewide Immunization Information System (USIIS). Allowing your immunization history to be shared with USIIS will aid you, and your health care providers to determine which immunizations you have received and which may still be needed.
By signing this consent form you are agreeing that Valley Women’s Health can share your immunization information with USIIS.
INTRODUCTION
We maintain protocols to ensure the security and confidentiality of your personal information. We have physical security in our building, passwords to protect databases, compliance audits, and virus/intrusion detection software. Within our practice, access to your information is limited to those who need it to perform their jobs.
At the offices of Valley Women’s Health, we are committed to treating and using protected health information about you responsibly. This Notice of Privacy Policies describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective April 14, 2003, and applies to all protected health information as defined by federal regulations.
YOUR HEALTH INFORMATION RIGHTS
Although your health record is the physical property of Valley Women’s Health, the information belongs to you. You have the right to:
Obtain a paper copy of this notice of privacy policies upon request, Inspect and obtain a copy of your health record as provided by 45 CFR 164.524 (reasonable copy fees apply in accordance with state law), Amend your health record as provided by 45 CFR 164.526,
Obtain an accounting of disclosures of your health information as provided by 45 CFR 164.528,
Request confidential communications of your health information as provided by 45 CFR 164.522(b), and
Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522(a) (however, we
UNDERSTANDING YOUR HEALTH RECORD
Each time you visit Valley Women’s Health a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
Basis for planning your care and treatment,
Means of communication among the many health professionals who contribute to your care,
Legal document describing the care you received,
Means by which you or a third-party payer can verify that services billed were actually provided,
Tool in educating health professionals,
Source of data for medical research,
Source of information for public health officials charged to improve the health of the state and nation,
Source of data for our planning and marketing, and
Tool by which we can assess and continually work to improve the care we render and outcomes we achieve.
Understanding what is in your record and how your health information is used.
OUR RESPONSIBILITIES
Our practice is required to:
Maintain the privacy of your health information,
Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you, Abide by the terms of this notice,
Notify you if we are unable to agree to a requested restriction, Accommodate reasonable requests you may have to communicate your health information.
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. We will keep a posted copy of the most current notice in our facility containing the effective date in the top, right-hand corner. In addition, each time you visit our facility for treatment, you may obtain a copy of the current notice in effect upon request.
We will not use or disclose your health information in a manner other than described in the section regarding Examples of Disclosures for Treatment, Payment, and Health Operations, without your written authorization, which you may revoke as provided by 45
CFR 164.508(b) (5), except to the extent that action has already been taken.
FOR MORE INFORMATION OR TO REPORT A PROBLEM
If you have questions and would like additional information, you may contact our practice’s Privacy Officer, at (801)756-9635. If you believe your privacy rights have been violated, you can either file a complaint with us, or with the Office for Civil Rights, U.S. Department of Health and Human Services (OCR). There will be no retaliation for filing a complaint with either our practice or the OCR. The address for the OCR regional office for Utah is as follows:
Office for Civil Rights
U.S. Department of Health and Human Services
1961 Stout Street – Room 1185 FOB Denver, CO 80294
EXAMPLES OF DISCLOSURE FOR TREATMENT, PAYMENT AND HEALTH OPERATIONS
We will use your health information for treatment. We may provide medical information about you to health care providers, our practice personnel, or third parties who are involved in the provision, management, or coordination of your care.
For example:
Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your medical information will be shared among health care professionals involved in your care. We will also provide your other physician(s) or subsequent health care provider(s) (when applicable) with copies of various reports that should assist them in treating you.
We will use your health information for payment. We may disclose your information so that we can collect or make payment for the health care services you receive.
For example:
If you participate in a health insurance plan, we will disclose necessary information to that plan to obtain payment for your care.
WE WILL USE YOUR HEALTH INFORMATION FOR REGULAR HEALTH OPERATIONS
We may disclose your health information for our routine operations. These uses are necessary for certain administrative, financial, legal, and quality improvement activities that are necessary to run our practice and support the core functions.
For example:
Members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide and to reduce healthcare costs.
APPOINTMENT REMINDERS
We may disclose medical information to provide appointment reminders (e.g., contacting you at the phone number you have provided to us and leaving a message as an appointment reminder).
DECEDENTS
Consistent with applicable law, we may disclose health information to a coroner, medical examiner, or funeral director.
WORKERS COMPENSATION
We may disclose health information to the extent authorized by and necessary to comply with laws relating to workers compensation or other similar programs established by law.
PUBLIC HEALTH
As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
RESEARCH
We may disclose information to researchers when their research has been approved and the researcher has obtained a required waiver from the Institutional Review Board/Privacy Board, who has reviewed the research proposal.
ORGAN PROCUREMENT ORGANIZATIONS
Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of donation and transplant.
AS REQUIRED BY LAW
We may disclose health information as required by law. This may include reporting a crime, responding to a court order, grand jury subpoena, warrant, discovery request, or other legal process, or complying with health oversight activities, such as audits, investigations, and inspections, necessary to ensure compliance with government regulations and civil rights laws.
SPECIALIZED GOVERNMENT FUNCTIONS
We may disclose health information for military and veteran’s affairs or national security and intelligence activities.
BUSINESS ASSOCIATES
There are some services provided in our organization through contacts with business associates. Some examples are billing or transcription services we may use. Due to the nature of business associates services, they must receive your health information in order to perform the jobs we’ve asked them to do. To protect your health information, however, when these services are contracted we require the business associate to appropriately safeguard your information.
PRACTICE MARKETING
We may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you (e.g., to notify you of any new tests or services we may be offering).
FOOD AND DRUG ADMINISTRATION (FDA)
We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
PERSONAL REPRESENTATIVE
We may disclose information to your personal representative (person legally responsible for your care and authorized to act on your behalf in making decisions related to your health care).
TO AVERT A SERIOUS THREAT TO HEALTH/SAFETY
We may disclose your information when we believe in good faith that this is necessary to prevent a serious threat to your safety or that of another person. This may include cases of abuse, neglect, or domestic violence.
COMMUNICATION WITH FAMILY
Unless you object, health professionals, using their best judgment, may disclose to a family member or close personal friend health information relevant to that person’s involvement in your care or payment related to your care. We may notify these individuals of your location and general condition.
DISASTER RELIEF
Unless you object, we may disclose health information about you to an organization assisting in a disaster relief effort. For all non-routine operations, we will obtain your written authorization before disclosing your personal information. In addition, we take great care to safeguard your information in every way that we can to minimize any incidental disclosures.
HIPAA – PERSONAL REPRESENTATIVE AUTHORIZATION
PURPOSE
This form allows you (the “Patient”) to give Valley Women’s Health and their health care provider’s permission (authorization) to disclose your protected health information (PHI) to a person that will act as your Personal Representative.
The information covered by this authorization is protected health information, including diagnoses; procedures; billing data; and treatment plans.
Each patient who wishes to name a Personal Representative must complete an authorization form. For example, if you expect your spouse to call us on your behalf, you need to fill out this form. If you do not wish to name a Personal Representative, please indicate below. You are not required to name a Personal Representative, but if you do not, we will not release your protected health information to anyone else who may call or write on your behalf. Your Personal Representative may be anyone of your choosing, such as a spouse, parent, child, friend, and you must provide the information below for each person before we can treat that person as your Personal Representative. If you need additional forms, we will be happy to copy this form for you.
Please Note: This authorization does not give your Personal Representative authority, either implied or direct, over any treatment or direct care decisions.
AUTHORIZED USE AND/OR DISCLOSURE
I authorize you to disclose my protected health information to the person(s) named below for the purpose of assisting with or facilitating my health care and payment of any health benefits. I acknowledge that my authorization is voluntary.
I understand that I have the right to limit the information you release under this authorization. Any such limitations must be described in Restrictions in this section.
This authorization to release information to my Personal Representative will automatically expire in three (3) years after the date of my last visit to Valley Women’s Health.
I understand that I have the right to revoke or end this authorization at any time and may do so by giving written notice of my decision to the Privacy Official at the office of Valley Women’s Health. I understand that my revocation of this authorization will not affect any action that has been taken or information that has already been released, based upon this authorization before receiving my request to revoke authorization.
I have had full opportunity to read and consider the content of this form. I understand that by accepting the terms, conditions, and policies contained in this electronic form, I am confirming my authorization that Valley Women’s Health and their healthcare providers may disclose my protected health information to the person(s) named on this form, for the purpose described above.