Covid 19 Test Registration Form | GetWell Urgent Care

Joint Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

GETWELL Urgent Care is required by law to maintain the privacy of your Protected Health Information (PHI). GETWELL Urgent Care and its Affiliated Entities provide clinically integrated services and consist of an organized health care arrangement (OHCA). This Notice describes how we will treat your PHI and how we may use and disclose your PHI to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. We may share your health information for treatment, payment and health operations as described in this Notice. This Notice also describes your rights to access and control your PHI. PHI is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information: Your PHI may be used and disclosed by the physician, our office staff and others outside of our offices that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the business, and any other use required by law. We may disclose PHI to family members, close friends or others concerned with your care and treatment.

Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your PHI may be provided to a physician to whom you have been referred or are receiving treatment from to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your PHI will be used to obtain payment for your health care services. For example, we may provide PHI to your insurance company to obtain authorization and payment for services rendered. We may contact the Guarantor for your visit in order to obtain payment.

Healthcare Operations: We may use or disclose your PHI in order to support our business activities. These activities include, but are not limited to business associates, quality assessment activities, internal investigations, performance reviews, and training employees. In addition, we will use a sign-in sheet at the registration desk where you will be asked to provide your name and insurance company. We may also call you by name in the waiting room when the physician is ready to see you. We may use or disclose your PHI to contact you to remind you of an appointment, to notify you of test results, to inform you of health-related services that may be of interest to you, and to check on your treatment, progress, and satisfaction with our services.

We may use or disclose your PHI in the following situations without your authorization: As required by Law, for Public Health issues, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donation, Preliminary Research Identification, Research with an IRB waiver, Criminal Activity, Military Activity, to avert a serious and imminent threat to a person or the public, National Security, to comply with Worker’s Compensation laws, Inmates, Disaster Relief and other Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services.

Other permitted and required uses and disclosures, such as for marketing or sale of your PHI to third parties, will be made only with your authorization. Once given, you may withdraw authorization at any time in writing delivered to the address given below. You have the right to inspect and copy your protected health information. Under federal law, you may not inspect or copy psychotherapy notes, information compiled in anticipation of, or use in, a legal proceeding, and PHI that is otherwise prohibited.

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 PHI for the purposes of treatment, payment or health care operations. Your request must be in writing, delivered to the address given below, and state the specific restriction requested and to whom you want the restriction to apply. If you have paid for your services in full and ask us not to disclose your visit to your insurance company, we will honor that request. We are not required to agree to any other restriction that you may request and if we believe it is in your best interest to permit use and disclosure of your PHI, it will not be restricted. You then have the right to use another health care professional.

You have the right to receive confidential communications from us by alternative means, or at an alternative location by notifying us in writing, delivered to the address given below. You have the right to obtain a paper copy of this notice from us, upon request to the Clinic Manager or our Privacy Officer. You may have the right to ask us to amend your protected health information. If we deny your written request for amendment, you have the right to deliver a statement of disagreement with us at the address given below and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. Your request must be in writing, delivered to the address given below. We are required to notify you if your unsecured PHI is involved in a reportable breach. You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. Or, you may file a complaint with us by mail or by contacting our Privacy Officer at (818) 864-4336. We will not retaliate against you for filing a complaint. GETWELL Urgent Care reserves the right to change the terms of this notice. Any change will apply to all PHI that we maintain. We post our current policy at each location and on our website. All written requests must be delivered to the Clinic Manager or mailed to HIPAA Privacy Officer.

I consent *

CONSENT FOR TREATMENT

I, the undersigned, consent to the care and treatment by the attending physician, his/her associates or assistants and advanced practice providers. Treatment includes but is not limited to x-rays, laboratory tests, vaccinations, administration and injection of medication, and to medical or surgical treatment. I acknowledge that no guarantees have been made as to the effects of such treatment. Treatment also includes consent to access and use my detailed prescription history from third party sources.

I consent *

ASSIGNMENT OF BENEFITS AND GUARANTEE OF ACCOUNT

I acknowledge full financial responsibility for any services rendered and I understand that the payment of charges incurred in this office is due at the time of service. I also understand that the charges not covered by insurance remain my responsibility and assign insurance benefits to this office. In the event my account is turned over to a collection agency, I agree to pay all costs of collection fees and/or attorney's fees and all court costs if any.

I consent *

GETWELL URGENT CARE PATIENT ELECTRONIC COMMUNICATION CONSENT FORM

Definitions: "Electronic communication" shall refer to e-mail, SMS (text messaging), facsimile transmissions, and/or all other forms of communication transmitted and/or received electronically. "Provider" shall refer to GETWELL URGENT CARE.

Receiving Electronic Communications: In order to enhance the patient experience, Provider may contact you by electronic communication for the following reasons:

To request your feedback on the care you received.
To remind you of any follow-up care.
To notify you that we need to speak with you.
To notify you of services that GETWELL Urgent Care may provide.

By selecting Yes, and signing below you understand and agree to be contacted through electronic communication related to this visit, and any future visits. This information is only used for GETWELL Urgent Care purposes and is governed by the same HIPAA protection as all other information. In the future, even if you select to receive electronic communications today, you may opt-out of receiving electronic communication at any time by notifying us in writing (including responding via text message). For SMS communication, standard telephone minute and text charges may apply if we contact you.

RISK OF USING E-MAIL, SMS (“TEXT MESSAGING”), AND OTHER FORMS OF ELECTRONIC COMMUNICATION. Transmitting patient information by E-mail, SMS, and/or other forms of electronic communication has a number of risks that patients should consider before using these forms of communication. These include, but are not limited to, the following risks:

a. The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the 2013 Final Omnibus Rule Update recommends that E-mail that contains protected health information encrypted. However, SMS messages sent from this Provider are not encrypted, so they may not be secure. Therefore it is possible that the confidentiality of such communications may be breached by a third party.

b. E-mail and SMS messages can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.

c. E-mail and SMS senders can easily mis-assign an E-mail or SMS.

d. E-mail and SMS is easier to falsify than handwritten or signed documents.

e. Backup copies of E-mail and SMS messages may exist even after the sender or the recipient has deleted his or her copy.

f. Employers and on-line services have a right to inspect E-mail and SMS messages transmitted through their systems.

g. E-mail and SMS messages can be intercepted, altered, forwarded, or used without authorization or detection.

h. E-mail (and possibly SMS messages) can be used to introduce viruses into computer systems.

i. The Provider server and/or computer system could go down and E-mail and/or SMS message may not be received until the server is back on-line.

j. E-mail and SMS messages can be used as evidence in court.

CONDITIONS FOR THE USE OF E-MAIL, SMS (“TEXT MESSAGING”), AND OTHER FORMS OF ELECTRONIC COMMUNICATION. Provider cannot guarantee but will use reasonable means to maintain security and confidentiality of E-mail, SMS, and other forms of electronic communication information sent and received.

a. E-mail, SMS messaging, and other forms of electronic communication are not appropriate for urgent or emergency situations. Practice and Provider cannot guarantee that any particular electronic communication will be read and responded to within any particular period of time.

b. If the patient’s E-mail, SMS message, or other form of electronic communication requires or invites a response from Provider, and the patient has not received a response within two (2) business days, it is the patient’s responsibility to follow-up to determine whether the intended recipient received the electronic communication and when the recipient will respond.

c. The patient should schedule an appointment if the issue is too complex or sensitive to discuss via E-mail or SMS messages.

d. E-mail, SMS messages, and other forms of electronic communication may be printed and filed in the patient's medical record.

e. Although unlikely, office staff (if applicable) may receive and read your messages.

f. Provider will not forward patient identifiable electronic communications to any other party without the patient's prior written consent, except as authorized or required by law.

g. The patient should not use E-mail, SMS messages, or other forms of electronic communication for communicating sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, or substance abuse. Provider is not liable for breaches of confidentiality caused by the patient or any third party.

h. It is the patient's responsibility to follow up and/or schedule an appointment if warranted.

i. This consent will remain in effect until terminated in writing by either the patient or Provider.

j. In the event that the patient does not comply with the conditions herein, Provider may terminate patient’s privilege to communicate by E-mail, SMS, or other forms of electronic communication with Practice.

INSTRUCTIONS. To communicate by E-mail, SMS messaging, or other forms of electronic communication, the patient shall:

a. Avoid use of an electronic device that is not your own or unsecure.

b. Put the patient's name in the body of the message.

c. Key in the topic (e.g., medical question, billing question) in the subject line.

d. Inform Provider of changes in his/her E-mail address or SMS phone number.

e. Acknowledge any E-mail, SMS message, or other electronic communication received from the provider

f. Take precautions to preserve the confidentiality of all electronic communications.

g. Protect his/her password or other means of access to E-mail, SMS, and other forms of electronic communication

Getwell Urgent Care Patient Electronic Communication Consent

I consent *

Date: *

Signature: *

COVID-19 Test Scheduling and Registration