TERMS OF USE AND CONDITIONS OF SERVICE
PLEASE READ THESE TERMS CAREFULLY BEFORE RECEIVING SERVICES
By receiving healthcare services from this facility, you agree to be bound by these Terms of Use. If you do not agree to these terms, please inform our staff before receiving services.
1. ACCEPTANCE OF TERMS
By signing below or receiving services from this healthcare facility, you acknowledge that you have read, understood, and agree to be bound by these Terms of Use and all applicable laws and regulations.
2. DESCRIPTION OF SERVICES
This healthcare facility provides medical, diagnostic, therapeutic, and related healthcare services. The specific services provided will be determined by your healthcare provider based on your individual health needs and in accordance with accepted medical standards of care.
3. PATIENT RESPONSIBILITIES
As a patient, you agree to:
• Provide accurate and complete information about your health history, current symptoms, medications, and allergies
• Follow the treatment plan prescribed by your healthcare provider
• Keep scheduled appointments or provide adequate notice of cancellation
• Treat staff, other patients, and facility property with respect
• Comply with facility policies and procedures
• Pay for services rendered in accordance with the Financial Responsibility Agreement
4. APPOINTMENT POLICY
• Appointments should be scheduled in advance when possible
• Please arrive 15 minutes before your scheduled appointment time
• If you need to cancel or reschedule, please provide at least 24 hours' notice
• Repeated no-shows or late cancellations may result in discharge from the practice
5. MEDICAL RECORDS
• Your medical records are maintained in accordance with applicable state and federal laws
• You may request copies of your medical records in writing
• A reasonable fee may be charged for copying and processing medical records
• Records will be retained for the period required by applicable law
6. COMMUNICATION
• We may contact you regarding appointments, test results, and health information
• You may specify your preferred method of communication
• For your protection, we may verify your identity before discussing health information
TEXT MESSAGE (SMS) CONSENT
By providing your mobile number to this practice and opting in, you agree to receive appointment reminders, re-evaluation notices, and appointment status updates by text message at the number on file. Message frequency varies based on your appointments. Message and data rates may apply. Consent is not a condition of receiving care. You may opt out of text messages at any time by replying STOP to any message, or by updating your communication preferences in the patient portal. Reply HELP for help, or contact our office. The SMS options you select apply only while consent is given; withdrawing consent opts you out of all text messages.
7. PATIENT PORTAL
If you use our patient portal:
• You are responsible for maintaining the confidentiality of your login credentials
• You agree not to share your account access with others
• The portal is provided for your convenience and is not intended for emergencies
• For urgent matters, please call our office or seek emergency care
8. PRESCRIPTION POLICY
• Prescription refill requests require 48-72 hours to process
• Controlled substances require an office visit and are subject to additional policies
• We do not prescribe medications to patients we have not evaluated
9. LIMITATION OF LIABILITY
To the fullest extent permitted by law, this healthcare facility and its providers shall not be liable for any indirect, incidental, special, consequential, or punitive damages arising from your use of our services, except in cases of gross negligence or willful misconduct.
10. DISPUTE RESOLUTION
Any disputes arising from these Terms of Use or the services provided shall first be addressed through our patient grievance process. If unresolved, disputes may be subject to mediation or arbitration as provided by applicable law.
11. MODIFICATIONS
We reserve the right to modify these Terms of Use at any time. Updated terms will be posted in our facility and on our website. Continued use of our services after modifications constitutes acceptance of the updated terms.
12. SEVERABILITY
If any provision of these Terms of Use is found to be invalid or unenforceable, the remaining provisions shall continue in full force and effect.
13. GOVERNING LAW
These Terms of Use shall be governed by and construed in accordance with the laws of the state in which this facility is located.
ACKNOWLEDGMENT
By signing below, I acknowledge that I have read, understood, and agree to these Terms of Use.
BUSINESS ASSOCIATE AGREEMENT ACKNOWLEDGMENT
(HIPAA Business Associate Disclosure)
IMPORTANT NOTICE REGARDING PROTECTED HEALTH INFORMATION
This notice explains how your Protected Health Information (PHI) may be shared with Business Associates who help us provide healthcare services to you.
WHAT IS A BUSINESS ASSOCIATE?
Under the Health Insurance Portability and Accountability Act (HIPAA), a Business Associate is a person or entity that:
• Performs certain functions or activities on behalf of, or provides certain services to, a healthcare provider
• Involves the use or disclosure of Protected Health Information (PHI)
CATEGORIES OF BUSINESS ASSOCIATES
We may share your Protected Health Information with the following types of Business Associates:
1. HEALTHCARE OPERATIONS
• Medical billing and coding services
• Claims processing and submission companies
• Healthcare clearinghouses
• Practice management consultants
• Quality assessment and improvement organizations
2. TECHNOLOGY SERVICES
• Electronic Health Record (EHR) system vendors
• Cloud storage and data hosting providers
• Health information exchange networks
• Secure messaging and communication platforms
• Patient portal providers
3. ADMINISTRATIVE SERVICES
• Medical transcription services
• Appointment scheduling services
• Medical records storage and retrieval companies
• Document destruction services
• Collection agencies (for patient accounts)
4. CLINICAL SERVICES
• Laboratory services
• Radiology and imaging centers
• Pharmacy services
• Durable medical equipment suppliers
• Home health agencies
• Specialty consultation services
5. INSURANCE AND FINANCIAL
• Health insurance companies and plans
• Workers' compensation carriers
• Third-party administrators
• Utilization review organizations
• Independent review organizations
PROTECTIONS FOR YOUR INFORMATION
All Business Associates are required to:
• Sign a Business Associate Agreement (BAA) with us
• Use appropriate safeguards to protect your PHI
• Report any security incidents or breaches
• Ensure their subcontractors also comply with HIPAA requirements
• Return or destroy PHI when no longer needed
• Make PHI available for patient access requests
• Comply with the HIPAA Security Rule requirements
YOUR RIGHTS
You have the right to:
• Request a list of Business Associates who have received your PHI (accounting of disclosures)
• Request restrictions on certain disclosures (though we may not always be able to agree)
• File a complaint if you believe your privacy rights have been violated
• Receive notification if there is a breach of your unsecured PHI
MINIMUM NECESSARY STANDARD
We apply the "minimum necessary" standard when sharing your PHI with Business Associates, meaning we only share the information necessary to accomplish the intended purpose.
NO SALE OF PHI
Your Protected Health Information will never be sold to Business Associates or any other party. Any sharing of your information is solely for treatment, payment, or healthcare operations purposes.
QUESTIONS OR CONCERNS
If you have questions about our Business Associates or how your information is shared, please contact our Privacy Officer.
ACKNOWLEDGMENT
By signing below, I acknowledge that I have received and understand this notice regarding the disclosure of my Protected Health Information to Business Associates. I understand that:
• My healthcare provider uses various Business Associates to provide quality healthcare services
• All Business Associates are required to protect my PHI under HIPAA
• I have the right to request information about disclosures to Business Associates
• This acknowledgment does not authorize any uses or disclosures beyond those permitted by HIPAA