Crossover Health Medical Group
New Patient Registration
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.
Notice Of Privacy Practices (Effective Date: November 2018)
As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA): 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.
A. Our commitment to your privacy:
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:
- How we may use and disclose your PHI
- Your privacy rights in your PHI
- Our obligations concerning the use and disclosure of your PHI
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 on our website, and you may request a copy of our most current Notice at any time. We are required to abide by the terms of the notice currently in effect 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.
B. Your personal information:
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.
C. Our privacy practices:
D. If you have questions about this Notice, please contact:
Crossover Health Medical Group, PC 101 W. Avenida Vista Hermosa Ste. 120 San Clemente, CA 92672
E. We may use and disclose your PHI in the following ways:
The following categories describe the different ways in which we may use and disclose your PHI. 1. Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may also receive and disclose your PHI to other health care providers for purposes related to your treatment. 2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. In addition, and by way of example of disclosures for payment purposes, we may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts. 3. Health care operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations. 4. Appointment reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment. 5. Treatment options. Our practice may use and disclose your PHI to inform you of potential treatment alternatives or other health-related benefits and services that may be of interest to you. 6. Health-related beneﬁts and services. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you. 7. Release of information to family/friends. Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. However, any such disclosure will be subject to legal requirements and our HIPAA and HITECH Policy. 8. Disclosures required by law. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.
F. Use and disclosure of your PHI in certain special circumstances:
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:
- Maintaining vital records, such as births and deaths;
- Reporting child abuse or neglect;
- Preventing or controlling disease, injury or disability;
- Notifying a person regarding potential exposure to a communicable disease;
- Notifying a person regarding a potential risk for spreading or contracting a disease or condition
- Reporting reactions to drugs or problems with products or devices;
- Notifying individuals if a product or device they may be using has been recalled;
- Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information; or
- Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.
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:
- Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement;
- Concerning a death we believe has resulted from criminal conduct;
- Regarding criminal conduct at our offices;
- In response to a warrant, summons, court order, subpoena or similar legal process;
- To identify/locate a suspect, material witness, fugitive or missing person; or
- In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).
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:
- (a) an adequate plan to protect the identifiers from improper use and disclosure; (b) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (c) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted;
- The research could not practicably be conducted without the waiver; and
- The research could not practicably be conducted without access to and use of the PHI.
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.
G. Receiving PHI from providers, insurance entities, and their business associates:
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.
H. Your written permission:
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 the applicable state law of the practice location, we may not share your health information with your employer or benefit plan unless you provide us an authorization to do so.
I. Other Restrictions:
Under the applicable state law of the practice location, there may be additional 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.
J. Your rights regarding your PHI:
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:
- The information you wish restricted;
- Whether you are requesting to limit our practice’s use, disclosure or both; and/or
- To whom you want the limits to apply.
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.
By using crossoverhealth.com (the “Website”), you signify your assent to these Terms and Conditions. If you do not agree to all of these Terms and Conditions of use, do not use this Website. Crossover Health is the owner of the Website and may revise and update these Terms and Conditions at any time. Your continued usage of the Website will mean you accept those changes.
Website Does Not Provide Medical Advice
The contents of the Website, such as scores, statistics, text, graphics, images, information, and other material contained or that may be contained on the Website (the “Content”) are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have seen on the Website. If you think you may have a medical emergency, call your doctor or 911 immediately. Crossover Health does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information. Reliance on any information provided by the Website is solely at your own risk.
Crossover Health is committed to protecting your personal information. The Website contains many of the same types of security features as other secure websites such as banking websites including: encryption, registration requirements, authorization, and password protection. The Website has several tools that allow for the recording and storage of your information. You are responsible for taking all reasonable steps to ensure that no unauthorized person shall have access to your devices or passwords or accounts. It is your sole responsibility to: (1) control the dissemination and use of sign-in name, screen name and passwords; (2) authorize, monitor, and control access to and use of your account and password; (3) promptly inform Crossover Health if you believe your account or password has been compromised or if there is any other reason you need to deactivate a password. To send us an email, use the “Contact Us” links located at the bottom of every page of our Website. You grant Crossover Health and all other persons or entities involved in the operation of the Website the right to transmit, monitor, retrieve, store, and use your information in connection with the operation of the Website. Crossover Health cannot and does not assume any responsibility or liability for your or third parties’ use or misuse of information transmitted or received using the Website’s tools and services.
The use of the Website and the Content is at your own risk. When using the Website, while advanced technological safeguards are in place, information will be transmitted over a medium that may be beyond the control and jurisdiction of Crossover Health and its affiliates. Accordingly, Crossover Health assumes no liability for or relating to the delay, failure, interruption, or corruption of any data or other information transmitted in connection the with use of the Website. The Website and the Content are provided on an “as is” basis. CROSSOVER HEALTH, ITS LICENSORS, AFFLIATIATES, AND ITS SUPPLIERS, TO THE FULLEST EXTENT PERMITTED BY LAW, DISCLAIM ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDING BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT OF THIRD PARTIES’RIGHTS, AND FITNESS FOR PARTICULAR PURPOSE. Without limiting the foregoing, Crossover Health, its licensors, affiliates and its suppliers make no representations or warranties about the following: 1. The accuracy, reliability, completeness, currentness, or timeliness of the content, software, text, graphics, links, or communications provided on or through the use of the Website. 2. The satisfaction of any government regulations or compliance of any software tools with regard to the content contained on the Website. In no event shall Crossover Health, its licensors, affiliates, its suppliers, or any third parties mentioned on the Website be liable for any damages (including, without limitation, incidental and consequential damages, personal injury/wrongful death, lost profits, or damages resulting from lost data or business interruption) resulting from the use of or inability to use the Website or the Content, whether based on warranty, contract, tort, or any other legal theory, and whether or not Crossover Health, its licensors, its suppliers, or any third parties mentioned on the Website are advised of the possibility of such damages. Crossover Health, its licensors, affiliates, its suppliers, or any third parties mentioned on the Website shall be liable only to the extent of actual damages incurred by you, not to exceed U.S. $1000. Crossover Health, its licensors, its suppliers, or any third parties mentioned on the Website are not liable for any personal injury, including death, caused by your use or misuse of the Website or Content. Any claims arising in connection with your use of the Website or Content must be brought within one (1) year of the date of the event giving rise to such action occurred. Remedies under these Terms and Conditions are exclusive and are limited to those expressly provided for in these Terms and Conditions.
Materials in the Website are protected by international trademark and copyright laws. You may use the materials on this Website for your personal, non-commercial purposes. You may not reproduce, duplicate, distribute (including by way of email, facsimile or other electronic means), publish, modify, copy or transmit material from the Website unless you have obtained Crossover Health’s prior written consent.
You agree not to use the Website or any of its features for any purpose that is unlawful or prohibited by the Terms. You are personally responsible for the material that you send and for adhering to rules of conduct on any page of the Website. Crossover Health reserves the right to deny access to any part of the Website at our sole discretion.
You agree to defend, indemnify, and hold Crossover Health, its officers, directors, employees, agents, licensors, affiliates and suppliers, harmless from and against any claims, actions or demands, liabilities and settlements including without limitation, reasonable legal and accounting fees, resulting from, or alleged to result from, your violation of these Terms and Conditions.
You expressly agree that exclusive jurisdiction for any dispute with Crossover Health, or in any way relating to your use of the Website, resides in the courts of the State of California and you further agree and expressly consent to the exercise of personal jurisdiction in the courts of the State of California in connection with any such dispute including any claim involving Crossover Health or its affiliates, subsidiaries, employees, contractors, officers, directors, telecommunication providers, and content providers. These Terms and Conditions are governed by the internal substantive laws of the State of California, without respect to its conflict of laws principles. If any provision of these Terms and Conditions is found to be invalid by any court having competent jurisdiction, the invalidity of such provision shall not affect the validity of the remaining provisions of these Terms and Conditions, which shall remain in full force and effect. No waiver of any of these Terms and Conditions shall be deemed a further or continuing waiver of such term or condition or any other term or condition.
These Terms and Conditions constitute the entire agreement between you and Crossover Health with respect to the use of the Website and Content.