Please read this Agreement carefully: It is a legally binding contract. By accepting it, you are electronically signing and agreeing to be bound by this New Patient Registration and each of the demarcated documents contained herein including: the Notice of Privacy Practices, General Consent and Patient Rights and Responsibilities. If you do not wish to be bound by this Agreement, you may not receive any services provided by Crossover Health Medical Group.
As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA):
Our practice is dedicated to maintaining the privacy of your individually identiﬁable health information (also called protected health information, or PHI). In conducting our business, we will receive information and create records regarding you and the treatment and services we provide to you. We are required by law to maintain the conﬁdentiality of health information that identiﬁes you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.
We realize that these laws are complicated, but we must provide you with the following important information:
The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices (the “Notice”). Any revision or amendment to the Notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our clinics in a visible location at all times, and you may request a copy of our most current Notice at any time. A revised Notice may be obtained by forwarding a written request to Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672.
We keep records of the medical care we provide you, and we may receive similar records from others. We use this information so that we, or other health care providers, can render quality medical care, obtain payment for services and enable us to meet our professional and legal responsibilities to operate our medical practice. We may store this information in a chart and in our computers. This information makes up your medical record. The medical record is our property; however, this notice explains how we use information about you and when we are allowed to share that information with others.
Crossover Health Medical Group, PC
101 W. Avenida Vista Hermosa Ste. 120
San Clemente, CA 92672.
The following categories describe the different ways in which we may use and disclose your PHI.
The following categories describe unique scenarios in which we may use or disclose your identiﬁable health information:
1. Public health risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:
2. Health oversight activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
3. Lawsuits and similar proceedings. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
4. Law enforcement. We may release PHI if asked to do so by a law enforcement ofﬁcial:
5. Deceased patients. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.
6. Organ and tissue donation. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.
7. Research. Our practice may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when an Internal Review Board or Privacy Board has determined that the waiver of your authorization satisﬁes all of the following conditions:
The use or disclosure involves no more than a minimal risk to your privacy based on the following:
8. Serious threats to health or safety. Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
9. Military. Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
10. National security. Our practice may disclose your PHI to federal ofﬁcials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal and national security activities authorized by law. We also may disclose your PHI to federal ofﬁcials in order to protect the president, other ofﬁcials or foreign heads of state, or to conduct investigations.
11. Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement ofﬁcials if you are an inmate or under the custody of a law enforcement ofﬁcial. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.
12. Workers’ compensation. Our practice may release your PHI for workers’ compensation and similar programs.
13. Change of Ownership. In the event that our practice is sold or merged with another organization, your medical record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.
14. De-Identiﬁed Data. We may use or share your PHI once it has been “de-identiﬁed.” PHI is considered de- identiﬁed when it has been processed in such a way that it can no longer personally identify you.
15. Limited Data Sets. We may also use a “limited data set” that does not contain any information that can directly identify you. This limited data set may only be used for the purposes of research, public health matters or health care operations. For example, a limited data set may include your city, county and zip code, but not your name or street address.
We want to make you aware that, just as Crossover Health Medical Group uses and discloses certain PHI in your treatment, our operations and management and certain payment practices, Crossover Health Medical Group receives PHI from other healthcare entities and their business associates including but not limited to: medical ﬁles, charts, laboratory testing results, imagining results, and insurance claims data. PHI that is received and maintained by Crossover Health Medical Group from outside entities is subject to the protections of relevant law and our HIPAA and HITECH policy.
Except as described in this Notice, or as otherwise permitted by law, we must obtain your written permission – called an authorization – prior to using or sharing health information that identiﬁes you as an individual. If you provide an authorization and then change your mind, you may revoke your authorization in writing at any time. Once an authorization has been revoked, we will no longer use or share your health information as outlined in the authorization form; however you should be aware that we won’t be able to retract a use or disclosure that was previously made in good faith based on what was then a valid authorization from you.
Except as speciﬁed above, under applicable state law, we may not share your health information with your employer or beneﬁt plan unless you provide us an authorization to do so.
There may be additional state laws regarding the use and disclosure of health information related to HIV status, communicable diseases, reproductive health, genetic test results, substance abuse, mental health and mental retardation. Generally, we will be bound by whatever law is more stringent and provides more protection for your privacy.
You have the following rights regarding the PHI that we maintain about you:
1. Conﬁdential communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of conﬁdential communication, you must make a written request to Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672 and inform us of the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
2. Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672.
Your request must describe in a clear and concise fashion:
3. Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672 in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672.
You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
5. Accounting of disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as part of the routine patient care in our practice is not required to be documented – for example, the doctor sharing information with the nurse; or the billing department using your information to ﬁle your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672.
All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure. The ﬁrst list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
6. Right to a paper copy of this notice. You are entitled to receive a paper copy of our Notice. You may ask us to give you a copy of this Notice at any time. To obtain a paper copy of this Notice, contact Crossover Health Medical Group at (949) 891-0328.
7. Right to ﬁle a complaint. If you believe your privacy rights have been violated, you may ﬁle a complaint with our practice or with the Secretary of the Department of Health and Human Services. To ﬁle a complaint with our practice, contact Crossover Health Medical Group, 101 W. Avenida Vista Hermosa Ste. 120, San Clemente, CA 92672. All complaints must be submitted in writing. You will not be penalized for ﬁling a complaint.
8. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identiﬁed by this Notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note: we are required to retain records of your care.
Again, if you have any questions regarding this Notice or our health information privacy policies, please contact Crossover Health Medical Group at (949) 891-0328.
I acknowledge that I have received the Notice of Privacy Practices for Crossover Health Medical Group, and have been provided an opportunity to review it. If you have any questions or would like a hard copy of this Notice, please ask for one at the front desk or contact Crossover Health Medical Group at (949) 891-0328.
I hereby give my consent for Crossover Health Medical Group to receive, use and disclose Protected Health Information (“PHI”) about me, including but not limited to medical charts, records, laboratory results, imaging results, insurance claims data and information, to carry out treatment, payment and health care operation (“TPO”) as described in the Notice of Privacy Practices. I recognize the need for medical care; authorize the Crossover Health Medical Group to render such medical and ancillary care, tests, procedures, drugs and other services and supplies under the general and speciﬁc instruction of the Crossover Health Medical Group. Except for emergency or extraordinary circumstances, it is my understanding that additional consents will be obtained by my treating physician if more invasive services are to be performed or if additional consents or authorizations are required by law. I understand and am aware that the practice of medicine is not an exact science and acknowledge that no guarantee has been made to me as to the result of treatment or examination. I understand that it is my right to consent, or to refuse consent, to any proposed procedure or therapeutic course.
I understand that Crossover Health Medical Group uses advanced technology to deliver quality care, and I consent to the use of this technology. If you have any questions regarding the technology used by Crossover Health Medical Group, please contact Crossover Health Medical Group at (949) 891-0328.
Also, with this consent Crossover Health Medical Group may:
As a partner in my health care, I have the following rights:
As a partner in my health care, I have the following responsibilities:
For California Residents:
Medical doctors are licensed and regulated by the Medical Board of California.
Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:
Texas Medical Board Attention: Investigations
333 Guadalupe, Tower 3, Suite 610
P.O. Box 2018, MC-263 Austin, Texas 78768-2018
Assistance in ﬁling a complaint is available by calling the following telephone number: 1-800-201-9353. For more information please visit our website at www.tmb.state.tx.us