I understand that Patient’s medical records are confidential and cannot be disclosed without my written authorization except as authorized by law. Authorized disclosures are addressed in the Notice of Privacy Practices I have received. I understand that Patient’s medical information includes past, present and future information and may include genetic testing / counseling, communicable disease information including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), records related to mental health treatment / psychiatric care and alcohol / substance abuse diagnosis or treatment (collectively, Medical Information). I authorize release of that Medical Information, as part of Patient’s medical record. I understand that UHC must keep Patient’s medical records for a time period required by law and then may dispose of them as permitted or required by law.
I authorize Urgent House Calls (UHC) to use Patient’s Medical Information for Patient’s treatment and related services. Unless I object below, I authorize UHC to release and send Patient’s Medical Information to Patient’s non-UHC health care providers electronically and/or through a Health Information Exchange, an organization that provides services to enable the electronic sharing of health-related information. Medical Information disclosed pursuant to this authorization may be used for treatment, payment and operational purposes. The Medical Information disclosed may become part of my non-UHC health care providers’ medical records and may be re-disclosed by the recipient and no longer protected by state or federal privacy laws. I understand that I can change my mind and withdraw this authorization at any time, but UHC cannot take back information that has already been electronically shared. This consent is valid unless I have withdrawn it.
I have been provided information regarding Patient Rights and Responsibilities. You may complain to us or to the Secretary 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 officer of your complaint at our office and main telephone number. We will not retaliate against you for filing a complaint.