PF-1000
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.
USES
AND DISCLOSURES:
TREATMENT.
Your health information may be used by staff members or disclosed to other
health care
professionals
for the purpose of evaluating your health to provide proper equipment and
supplies. For
example,
diagnosis and prognosis will be available in your medical records to all
healthy professionals
who
may provide treatment or who may be consulted by staff members.
PAYMENT.
Your health information may be used to seek payment from your health plan,
from other
sources
of coverage such as an automobile insurer, or from credit card companies
that you may use
to
pay for services. For example, your healthy plan may request and receive
information on date of service,
the
services provided and the medical condition being treated.
HEALTH
CARE OPERATIONS. Your health information may be used as necessary to support
the
day-to-day
activities and management of Cornell Surgical Co. For example, information
on the services
you
received may be used to support budgeting and financial reporting and activities
to evaluate and
promote
quality.
LAW
ENFORCEMENT. Your health information may be disclose to law enforcement
agencies, without
your
permission, to support government audits and inspections, to facilitate
law-enforcement investigations,
and
to comply with government mandated reporting.
PUBLIC
HEALTH REPORTING. Your health information may be disclosed to public
health agencies
as
required by law. For example, we are required to report certain communicable
diseases to the state’s
public
health department.
OTHER
USES AND DISCLOSURES REQUIRES YOUR AUTHORIZATION. Disclosures of
your
health
information or its use for any purpose other than those listed about requires
your specific
written
authorization. If you change your mind after authorizing a use or
disclosure of your information
you
may submit a written revocation of the authorization. If you change
your mind after authorizing a use
or
disclosure of your information you may submit a written revocation of the
authorization. However, your
decision
to revoke the authorization will not affect or undo any use or disclosure
of information that occurred
before
you notified us of your decision.
Additional
Uses of Information
Your
health information will be used by our staff to notify you of orders ready
for pick up or delivery
and
appointment reminders.
Individual
Rights
You
have certain rights under the federal privacy standards. Theses include:
The
right to request restrictions on the use and disclosure of your protected
health information
The
right to receive confidential communications concerning your medical conditions
and treatment
The
right to inspect and copy your protected health information
The
right to amend or submit corrections to your protected health information
The
right to receive an accounting of how and to whom your protected information
has been disclosed
The
right to receive a printed copy of this notice
Cornell
Surgical Co. Duties
We
are required by law to maintain the privacy of your protected health information
and to provide
you
with this notice of privacy practices. We are also required to abide
by the privacy practices that
are
outlined in this notice.
Right
to Revise Privacy Practices
As
permitted by law, we reserve the right to amend or modify our privacy policies
and practices.
These
changes in our policies and practices may be required by changes in federal
and state laws
and
regulations. Whatever the reason for these revisions, we will provide
you with a revised notice.
The
revised policies and practices will be applied to all protected health
information that we maintain.
Request
to Inspect Protected Health Information
As
permitted by federal regulation, we require that requests to inspect or
copy protected health
information
be submitted in writing. You may obtain a form to request access
to your records by
contacting
our office.
Complaints
If
you would like to submit a comment or complaint about our privacy practices,
you can do so
by
sending a letter outlining your concerns to:
Cornell Surgical Co.
30 New Bridge Road
Bergenfield, NJ 07621
Attn: Privacy Officer
If you
believe your privacy rights have been violated, you should call the matter
to our attention by
sending
a letter describing the cause of your concern to the same address above.
You will not be
penalized
for filing a complaint.
Contact
person
For
further information regarding our policies, you can call our privacy officer
at 201-384-9000.
Effective
Date
This
notice is effective March 10, 2003
PF-2000
Consent to Use and Disclosure of Protected Health Information
Use
and Disclosure of Your Protected Health Information
Your
protected health information will be used by Cornell Surgical Co. or disclosed
to others for
the
purpose of providing proper equipment/supplies, obtaining payment, or supporting
day-to-day
operations
of the company.
Notice
of Privacy Practices
You
should review the Notice of Privacy Practices for a more complete description
of how your
protected
information may be used or disclosed. You may review the notice prior
to acknowledging
this
consent.
Requesting
a Restriction on the Use or Disclosure of Your Information
You
may request a restriction on the use or disclosure of your protected health
information.
Cornell
Surgical Co. may or may not agree to restrict the use or disclosure of
your protected
information.
If Cornell Surgical Co. agrees to your request, the restriction will be
binding on
the
company. Use or disclosure of protected information in violation
of an agreed upon restriction
will
be a violation of the federal privacy standards.
Reservation
of Right to Change Privacy Practices
Cornell
Surgical Co. reserves the right to modify the privacy practices outlined
in the notice.
I
have reviewed this consent form and give my permission to Cornell Surgical
Co. to use
and
disclose my health information in accordance with it. I fully understand
this consent
and
I understand that I do not have to sign and return this form if I agree.
If I decline
or modify the terms of this consent I must sign and return this
form to Cornell
Surgical Co. signifying my decline or restrictions.
Revocation
of Consent
By
signing this form you are revoking your consent to the use and disclosure
of your protected
health
information. I
wish to have the following restrictions to the use and disclosure of my
health
information:
_______________________________________________________________________________
Patient/client
signature X_____________________________________________ Date X_____________________
Patient/client
print X______________________________________________
_______________________________________________________________________________
FOR
OFFICE USE ONLY
Consent
received by__________on___________and placed into pt/client file on__________
Any questions and/or
comments pertaining to this website or
Cornell Surgical Co.
can be e-mailed to: info@cornellsurgical.com.
©2009 CORNELL SURGICAL
CO.
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