pediatric occupational, massage/touch, physical and speech ...€¦ · documentation of consent for...
TRANSCRIPT
Private Massage Consent Form
Massage therapy for a child is not intended to replace other forms of healthcare. Used as a form of adjunctive healthcare, potential benefits for the child include:
Skeletal Digestive Respiratory
• Aids in supporting good posture andbalance
• Reduces muscle tension that could leadto potential medical problems
• Increases nutrient flow to bones
• May relieve constipation• May relieve gas• May reduce water
retention• May improve GI function
• Improves breathingpatterns
• Helps reduce respiratoryproblems
• Relieves tension in thechest allowing the lungs toexpand more fully
Muscular Circulatory Nervous
• Relieves muscle tension and spasm• Aids in removal of lactic acid & carbonic
acid• Increases the flow of blood and nutrients
to muscles• Can increase or decrease muscle tone
depending upon amount of pressure• May decrease aversion to tactile
stimulation
• Stimulates blood andlymph circulation
• Helps strengthen theimmune system
• Releases toxins held inthe body
• Relaxes and calms• Improves sleep patterns• Raises endorphin levels,
promoting healing• Provides a safe and easy
release from frustrationand hyperactive behavior
• The Vagus Nerve isstimulated influencing foodabsorption hormones(Insulin & Glycogen) &attentiveness
Contradictions for Pediatric Massage Include
• Fever/Temperature • Acute infection, staph infection, illness or disease• Life threatening medical condition • Unhealed umbilical cord (tummy massage contraindicated)• Swollen lymph nodes • Blood clots or a blood condition• Diarrhea or other sickness • Inflammation• H1gh Blood Pressure • Hernia• Osteoporosis • Varicose Veins• Broken Bones • Deep Vein Thrombosis• Pain • Lability• Thrombocytopenia • Recent immunization/vaccination (wait 48- 72 hours)• Skin disorder/condition which may be contagious or cause inflammation (fungus, rashes, herpes)
Hearts and Hands Therapy Services Inc. Pediatric Occupational, Massage/Touch, Physical and Speech Therapy
1350 Pennsylvania Avenue McDonough, GA 30253 Page -1-
p (844) 543-8437 f (844) 471-3799
www.HeartsAndHandsTherapy.com
2001 Professional Pkwy Suite 220 Woodstock, GA 30188
Common Precautions for Pediatric Massage Include
• Apnea • Bradycardia • Tachycardia • Abdominal Distention• Gastrointestinal or Jejunostomy feeding tubes • Inflammations • Edema• Dysplasia • Hemophilia • Jaundice • Recent Surgery• HIV/AIDS • Tumors • Cancer • Seizure Disorders• Agitation • Impulsivity • Hydrocephalus
Child's Name: _______________________________________________ Birthdate: _______________________
Caregiver's Name: ____________________________________________
Address: ____________________________________________________
City: ________________________________________ State: _____________ Zip: _________
Phone: ______________________________________ Cell/Pager: ___________________
Email: _______________________________________________________
Referred By: __________________________________________________
In case of emergency.
My healthcare provider is: ________________________________________
Phone: ________________________
Please indicate any of the high-risk factors, complications that I should be aware of:
Is there other relevant information about the pregnancy, childbirth, about you or the child, that I should know?
I, _____________, understand that my child will be participating in pediatric massage therapy as a form of adjunct health care
I have noted above all complications, risks, or conditions my child has experienced AND I have obtained my child's healthcare providers release.
I understand that my child will receive pediatric massage therapy as a form of adjunctive health care only and that it is not a substitute for other healthcare provided by a medical doctor or another licensed provider.
I hereby release and hold harmless and defend the practitioner from any claims, liability, demands and causes of action from my and my child's participation in this therapy.
Signature: ___________________________ Date: ________ Print Name: ______________________________
Practitioner's Signature: ______________________ Date: _______ Print Name: __________________________
Hearts and Hands Therapy Services Inc. Pediatric Occupational, Massage/Touch, Physical and Speech Therapy
1350 Pennsylvania Avenue McDonough, GA 30253 Page -2-
p (844) 543-8437 f (844) 471-3799
www.HeartsAndHandsTherapy.com
2001 Professional Pkwy Suite 220 Woodstock, GA 30188
Pediatric Client Intake Form
Child's Name ___________________________________________________________ Birthdate _____________Age ______
Street -____________________________________________ City _______________________ State ______ Zip __________
Parent Occupation/Employer _____________________________________________________________________________
Please mark your goals for your child's Pediatric Massage Program:
Provide Comfort
Reduce stress
Ease Depression
Reduce muscle hyper tonicity
Improve gastrointestinal functioning
Promote orientation of extremities toward midline
Improve pulmonary functions
Reduce lethargy
Promote growth for baby born prematurely/child
Improve attentiveness and responsiveness
Decrease hypersensitivity to touch
Enhance child's body awareness
Promote relaxation
Reduce pain
Decrease anxiety
Improve muscle tone (decrease hypo tonicity)
Improve joint mobility I range of motion
Reduce chronic fatigue
Decrease symptoms of atopic dermatitis
Reduce colic I chronic abdominal pain
Improve self-soothing behavior
Improve sleep patterns
Encourage vocalization
Promote parent-child bonding
Other Goals: ____________________________________________________________________________________________
Health History
Birth History: Biological Child Adopted Foster Child
Weeks’ gestation: _____ Delivery: Vaginal Forceps C-Section Vacuum Extraction
Postpartum complications? No Yes (describe): _______________________________________________________
Is your child currently under the care of a primary healthcare provider? Yes No
Name of healthcare provider: _____________________________________________________________________________
Name of healthcare facility: _______________________________________________________________________________
Location: _____________________________________________________________________ Phone: __________________
May I exchange information when necessary with this provider? Yes No
Hearts and Hands Therapy Services Inc. Pediatric Occupational, Massage/Touch, Physical and Speech Therapy
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2001 Professional Pkwy Suite 220 Woodstock, GA 30188
My child is developing:
like an average child for his/her age in all areas of development
differently than an average child his/her age in any area of development.
Describe: ____________________________________________________________________________________
Please list medications, supplements or homeopathies the child is now taking:
Medication/Herb/etc. Reason Started Dosage
_____________________ ____________________________ ___________ ___________
_____________________ ____________________________ ___________ ___________
_____________________ ____________________________ ___________ ___________
_____________________ ____________________________ ___________ ___________
Please mark any of the following that your child now has or has had in the past. Identify the condition and location where applicable
Now Past Now Past Condition
Respiratory Conditions (includes sinus, lung and bronchial conditions. etc.) Type_________________________________ Location ______________________________
Circulatory Conditions(Includes heart. blood pressure, arteries and venous conditions. etc.) Type__________________________________ Location ______________________________
Reproductive Conditions(includes pregnancy, prostate, menstruation) Type__________________________________ Location ______________________________
Digestive Conditions(includes constipation, diarrhea, ulcers) Type__________________________________ Location ______________________________
Condition
Skin Conditions(includes rashes. topical allergies, fungal Infections. etc.) Type__________________________________ Location ______________________________
Muscle Conditions(Includes strains, tendonitis. spasms, cramps) Type_________________________________ Location ______________________________
Joint Conditions(Includes sprain, arthritis, degenerating joints) Type_________________________________ Location ______________________________
Nervous System Conditions(Includes numbness. tingling, nerve damage, shingles, etc.) Type_________________________________ Location ______________________________
Infectious or Communicable ConditionsType_________________________________ Location ______________________________
Other Conditions(Includes any other health condition not previously listed) Type_________________________________ Location ______________________________
Hearts and Hands Therapy Services Inc. Pediatric Occupational, Massage/Touch, Physical and Speech Therapy
1350 Pennsylvania Avenue McDonough, GA 30253 Page -4-
p (844) 543-8437 f (844) 471-3799
www.HeartsAndHandsTherapy.com
2001 Professional Pkwy Suite 220 Woodstock, GA 30188
Other medical conditions, symptoms and/or further explanations
Please list any recent accidents, illnesses or surgeries (past 2 years --or those that are still affecting your child
Please list any special dietary/nutritional considerations: (i.e.: gluten-free diet, allergies)
How do these symptoms affect the child's daily life?
Therapeutic History
Has your child ever received massage or another bodywork therapy (professionally or by a parent's touch)? (example: yoga therapy, cranial sacral therapy, bio aquatic therapy) Yes No If yes, please explain:
Please list other complementary therapies or educational programs in which your child participates:
Therapy/Program Reason Started Practitioner
_________________________________ _______________________ __________ ____________________
_________________________________ _______________________ __________ ____________________
_________________________________ _______________________ __________ ____________________
_________________________________ _______________________ __________ ____________________
May I exchange information when necessary with these providers? Yes No Has your child been evaluated for or diagnosed with Sensory Integration Disorder? Yes No If yes, please explain evaluation, diagnosis and/or therapy program: __________________________________________________________________________________________________________
Hearts and Hands Therapy Services Inc. Pediatric Occupational, Massage/Touch, Physical and Speech Therapy
1350 Pennsylvania Avenue McDonough, GA 30253 Page -5-
p (844) 543-8437 f (844) 471-3799
www.HeartsAndHandsTherapy.com
2001 Professional Pkwy Suite 220 Woodstock, GA 30188
Never Some Often Always In the past This is a Problem
Seem irritated when touched?
Bang or hit head on purpose?
Seem overly aware of touch. texture or temperature?
Have an increased response to pain?
Lack awareness of being touched?
Bite. chew or suck on blanket/pacifier/something to calm
Frequently bump into or push people or items?
Have a strong need to touch objects and people?
Try to bite people?
Dislike being bounced, rocked or swung?
Seek out rough-housing play?
Have fear in space (i.e. on stairs, heights. etc. )?
Dislike being off balance?
Personal History
Please describe your child's communication style: Verbal Word Approximations ASL PECS Augmentative Device Gestures None Other:______________________________________________________________________________
How does your child deal with change? ____________________________________________________________________________________
What types of methods does your child use to manage stressful situations (self-soothing techniques)? _____________________________________________________________________________________ ______________________________________________________________________________________
How do you deal with it? What makes your child:
Happy ?
Sad ?
Angry ?
Stressed ?
Excited ?
Dislike being held or cuddled
Hearts and Hands Therapy Services Inc. Pediatric Occupational, Massage/Touch, Physical and Speech Therapy
1350 Pennsylvania Avenue McDonough, GA 30253 Page -6-
p (844) 543-8437 f (844) 471-3799
www.HeartsAndHandsTherapy.com
2001 Professional Pkwy Suite 220 Woodstock, GA 30188
Does your child attend school/preschool/daycare? Yes No
If yes, what are his/her teacher's name(s)? _____________________________________________________________________
What are the names/types of his/her pets? ____________________________________________________________________
What are the names of his/her siblings? ______________________________________________________________________
What are the names of his/her friends? ______________________________________________________________________
What types of exercise interests your child? ____________________________________________________________________
How does your child prefer to spend his/her time (hobbies/interests)? ______________________________________________
I have listed all my child's known medical conditions and physical limitations and will inform the massage therapist in writing of any changes between bodywork sessions. I understand that a massage therapist must be aware of any and all existing physical conditions that my child has in order to provide appropriate massage. I further understand that a massage therapist neither diagnoses nor prescribes for illness, disease, or any other medical, physical, or emotional disorder. nor performs any thrusting joint or spinal manipulations or adjustments. I am responsible for consulting a qualified primary care provider for any physical ailment that my child may have.
I agree I will give twenty-four (24) hours notice to cancel any bodywork session to avoid being
charged.
Signed ______________________________________________________________Date ________________
Parent/Legal Guardian of ___________________________________________________________________
Hearts and Hands Therapy Services Inc. Pediatric Occupational, Massage/Touch, Physical and Speech Therapy
1350 Pennsylvania Avenue McDonough, GA 30253 Page -7-
p (844) 543-8437 f (844) 471-3799
www.HeartsAndHandsTherapy.com
2001 Professional Pkwy Suite 220 Woodstock, GA 30188
Documentation of Consent for Pediatric Massage Therapy
I, (Print Name) ______________________________________, spoke to the parent/guardian of ____________________________ ( in person/ on the phone) about Pediatric Massage Therapy. I informed them that this is treatment has been cleared by the child's physician.
I discussed risks and benefits of massage. Benefits include relaxation, pain relief and comfort. Risks include allergy to massage oil/lotion(list type) ___________________________________________ , emotional release related to relaxation, and musculoskeletal soreness.
Opportunity was given for them to ask any questions and these questions were answered.
Questions asked:
Was the use of an interpreter required? Yes No
The parent/guardian stated understanding of this intervention and gave permission for Massage.
Signatures
Person obtaining consent: _______________________________________
Interpreter: _______________________________________
Date/time: ______________________
Parent/guardian: ______________________
Witness: ______________________
Date/Time: ______________________
Hearts and Hands Therapy Services Inc. Pediatric Occupational, Massage/Touch, Physical and Speech Therapy
1350 Pennsylvania Avenue McDonough, GA 30253 Page -8-
p (844) 543-8437 f (844) 471-3799
www.HeartsAndHandsTherapy.com
2001 Professional Pkwy Suite 220 Woodstock, GA 30188
Appointment Times
Preferred Appointment Times/Schedule
Monday Tuesday Wednesday Thursday Friday Saturday Sunday 7 a.m to 8 a.m. 8 a.m to 9 a.m. 9 a.m to 10 a.m. 10 a.m to 11 a.m. 11 a.m to 12 p.m. 12 p.m to 1 p.m. 1 p.m to 2 p.m. 2 p.m to 3 p.m. 3 p.m to 4 p.m. 4 p.m to 5 p.m. 5 p.m to 6 p.m.
Cannot attend Times (Please specify which days/time you absolutely cannot attend, we will make an effort to use your preferred times above, and will not schedule you for the lists times below.)
Monday Tuesday Wednesday Thursday Friday Saturday Sunday 7 a.m to 8 a.m. 8 a.m to 9 a.m. 9 a.m to 10 a.m. 10 a.m to 11 a.m. 11 a.m to 12 p.m. 12 p.m to 1 p.m. 1 p.m to 2 p.m. 2 p.m to 3 p.m. 3 p.m to 4 p.m. 4 p.m to 5 p.m. 5 p.m to 6 p.m.
Additional information regarding scheduling of your appointments.
Hearts and Hands Therapy Services Inc. Pediatric Occupational, Massage/Touch, Physical and Speech Therapy
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1350 Pennsylvania Avenue McDonough, GA 30253 Page -9-
p (844) 543-8437 f (844) 471-3799
www.HeartsAndHandsTherapy.com
2001 Professional Pkwy Suite 220 Woodstock, GA 30188
CANCELLATION AND NO SHOW POLICY
CANCELLATION POLICY Your child’s therapy is very important, and Hearts and Hands Therapy Services wants to provide the most effective services to all clients. We are committed to helping improve your child’s overall development; however, your child’s therapy will not progress if too many sessions are missed.
We understand that sometimes a session must be canceled due to illness or other conflicts, but we ask that you give your therapist a 24-HOUR CANCELLATION NOTICE.
If you need to cancel your child’s appointment on the same day as the therapy, please call your child’s therapist as soon as possible. If you are not able to reach him/her, please leave a message on their phone and call the office so that we can try to notify them as well. If therapy is cancelled less than 24 hours in advance, you will be charged a no-show fee of $30 for the missed session.
NO SHOW POLICY If you do not cancel your child’s appointment, it is considered a “No Show”.
The HHTS policy states that a client may be discharged from therapy or placed on a waiting list if there have been more than 2 “No Shows”.
It is your responsibility to contact your therapist if you must cancel the therapy session or have a problem with your child’s appointment.
Child’s Name: _______________ Parent/ Guardian Signature: __________________Date: ____________
Hearts and Hands Therapy Services Inc. Pediatric Occupational, Physical and Speech Therapy
1350 Pennsylvania Avenue McDonough, GA 30253 Page -10-
p (844) 543-8437 f (844) 471-3799
www.HeartsAndHandsTherapy.com
2001 Professional Pkwy Suite 220 Woodstock, GA 30188
Photo Consent Form I, _______________________, AUTHORIZE the use of photographs of my child,______________________, for any forms of media advertising for Hearts and Hands Therapy Services, Inc. Types of media include videos, websites, magazines, photographs, flyers, or other similar publications.
Parent/ Guardian Signature: _____________________________________________Date: ____________
Or I, ______________________, DO NOT AUTHORIZE the use of photographs of my child, ___________________, for any forms of media advertising for Hearts and Hands Therapy Services, Inc. Types of media include videos, websites, photographs, flyers, or other similar publications.
Parent/Guardian Signature: ________________________Date: ____________
Privacy Practices and Procedures Acknowledgement Form I, ____________________________, (client, or guardian if under 18) understand that Hearts and Hands Therapy Services, Inc. may be provided access to, or create on my behalf, certain protected, identifiable, health information and that I have certain rights to the restriction of disclosure and use of such information. I hereby, acknowledge that on the ___ day of, ________ , ______
I was presented with a copy of Hearts and Hands Therapy Services, Inc.’s HIPA Notice of Privacy Practices pursuant to HIPA and 45 C.F.R. Parts 260 and 164 and applicable state law. I have reviewed the Notice and understand its terms or have been provided an opportunity to have the same explained to me.
Parent/ Guardian Signature: _______________________________________________________________
Hearts and Hands Therapy Services Inc. Pediatric Occupational, Physical and Speech Therapy
1350 Pennsylvania Avenue McDonough, GA 30253 Page -11-
p (844) 543-8437 f (844) 471-3799
www.HeartsAndHandsTherapy.com
2001 Professional Pkwy Suite 220 Woodstock, GA 30188
Credit Card on File Agreement
We have implemented a new policy, which requires all Hearts and Hands Therapy Services (HHTS) clients to keep a credit card on file for payment purposes. Our system enables us to maintain your credit card information securely on file and which can only be accessed under the terms specified below. By providing us with your credit card information you are giving HHTS permission to automatically charge your credit card if payment is not made by you within 30 days of your invoice. Please note there is a 5% fee after your invoice is over 30 days old. The billed amounts will match the patient responsibility amount as determined by your insurance. There are no co-pays or fees for services if you have Medicaid or Deeming Waiver Medicaid as primary or secondary insurance. In the event of loss of Medicaid you agree to notify HHTS immediately. Failure to do so will result in potential charges to you at the Medicaid Rate.
Any missed appointment without cancellation will result in the credit card on file being charged the no show fee of $30.00.
If the credit card information we have on file changes for any reason, you must notify HHTS as soon as possible. If you have any questions about a charge, please notify us within 15 days. After 30 days all charges will be assumed to be correct. We will maintain a clear record of all payments and charges. However, in the result that an overpayment occurs your account will be credited on the upcoming invoice or if the balance is zero a reimbursement can be put back on the same credit card or a check can be mailed directly to you. A receipt will be sent to you from our credit card processing company. In the event of a declined charge you will be asked for a new credit card number and or payment before continuing therapy services.
I HAVE READ AND UNDERSTAND THE CREDIT CARD ON FILE AGREEMENT AND AUTHORIZE HHTS TO CHARGE MY CREDIT CARD AS ABOVE STATED ABOVE
Child’s Name:__________________________________________________________________________
Please select one of the following Visa MasterCard American Express Discover
Name on Credit Card: ____________________________________________________________________
Billing Address:_________________________________________________________________________
City: _______________________State_________________ Zip code: __________
Credit Card Number: _____________________________Exp. Date: ___________ Security Code: _______
_____ Initial here if you would like all invoices including new invoices to be billed to above credit card.
Please check one Weekly Monthly
Signature: _________________________________________________Date: _________________
Hearts and Hands Therapy Services Inc. Pediatric Occupational, Physical and Speech Therapy
1350 Pennsylvania Avenue McDonough, GA 30253 Page -12-
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2001 Professional Pkwy Suite 220 Woodstock, GA 30188
HIPPA NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
1) Hearts and Hands Therapy Services, Inc., hereinafter Hearts and Hands, is permitted to make use ofand to disclose health care information for the purposes of treatment, payment and health careoperations. The following are examples of use or disclosure for each of the listed purposes:A. Example of use or disclosure for the purpose of treatment: Private health information may be
disclosed to gain knowledge about our diagnosis or prognosis to help us treat your conditionappropriately.
B. Example of use or disclosure for the purpose of payment: Private health information may bedisclosed so that we may collect payment from your insurance company or other healthcarecoverage.
C. Example of use or disclosure for the purpose of health care operations: Hearts and Hands maycontact the individual to provide appointment r e m i n d e r s , in f or ma t i on a b o u t yourtreatment a l ternat ives o r other health related benefits services that may be of interest to theindividual.
2) Hearts and Hands is permitted or required to use or disclose protected health informationwit hout the individuals wr i t ten authorization for the following purposes:A. To maintain a directory of individuals.B. To a family member, other relative or a close friend of the individual, or any other person identified
by the individual, to the extent disclosure is directly relevant to the individual’s care or paymentrelated to the individual’s care.
C. To notify a family member, a personal representative of the individual or another personresponsible for the care of an individual of the individual’s location, general condition or death.
D. Where necessary, to assist a public or private entity authorized by law or by its charter, in disasterrelief efforts. E. Where the disclosure or use is required by law.
E. To assist the public health authority that is authorized by law to collect or receive such informationfor the purpose of
F. preventing or controlling disease, injury or disability.G. To assist a public health authority or other appropriate government authority authorized by law
to receive reports of child abuse or neglect.H. To provide information regarding a person subject to the jurisdiction of the Food and Drug
Administration with respect of an FDA regulated product or activity for which that person hasresponsibility.
I. Where authorized by law to notify an individual, who may have been exposed to a communicabledisease or may otherwise by a risk of contracting or spreading a disease or condition.
J. To an employer to conduct an evaluation relating to medical surveillance in the workp l a c e orevaluate whether the individual has suffered a work-related illness or injury and where evaluationnotice of such disclosure is given to the individual.
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K. Where made to a government authority about an individual reasonable believed to be the victimof abuse or neglect.
L. To a health oversight agency for oversight activities authorized by law.M. Pursuant to a court order or properly restricted subpoena upon notice.N. To a law enforcement official for the purpose of identifying or locating a suspect, fugitive, material
witness or missing person.O. To a law enforcement official for the purpose of identifying who is or is suspected to be the victim
of a crime.P. To a law enforcement official regarding a death if there is reason to believe the death resulted from
criminal conduct.Q. To law enforcement official if the information constitutes evidence that a crime has occurred on
Hearts and Hands premises.R. To a law enforcement officer in response to a medical emergency, if necessary, to alert such
officer to aspects of a crime.S. To a coroner of medical examiner for the purpose of identifying a deceased person, determining
the cause of death, or other duties as authorized by law.T. To funeral directors consistent with applicable law to carry out their duties with respect to the
decedent.U. To organ procurement o r g a n i z a t i on s e n g a g e d in the procurement, b a n k i n g or
transplantation o f organs, eyes or tissue.V. To assist, where necessary, for research purposes where adequate restrictions are in place.W. Where necessary to prevent or lessen a serious and imminent threat to the health or safety of
the person or the public.X. Where the individual is Armed Forces personnel and the information is deemed necessary by
military command authorities to assure proper execution of military mission.Y. Where the individual i s foreign mi l i tary personnel a n d the information i s deemed
n e ce s sa r y b y foreign Military command authorities to assure proper execution of the militarymission.
Z. To authorized federal officials to conduct lawful intelligence gathering, counterintelligence, and othernational security activities authorized by the National Security Act.
AA. To authorized federal officers for the provision of protective services to the President. BB. To correctional institutions or authorized law enforcement officers for the provision of care of
inmates and the safety and administration of the correctional facility. CC. To the extent necessary to comply with law relating to workers’ compensation or other similar
programs and:DD. Any other permitted purposes define in 45 C.F.R. Parts 160 and 164.
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2001 Professional Pkwy Suite 220 Woodstock, GA 30188
3) Other uses and disclosures of information wil l be made only with the individual’s writtenauthorization. The individual may revoke such authorization at any time provided that therevocation is in writing except to the extent that:A. Hearts and Hands has acted in reliance thereon, orB. If the authorization was provided as a condition to obtaining insurance coverage or the law
permits the insurer the right to contact regarding the claim under the policy itself.4) The individual retains the following rights with respect to protected information:
A. The right to request restrictions on certain uses and disclosures of protected health information.Hearts and Hands is not required to agree to a requested restriction.
B. The individual retains the right to receive confidential co mm u n ic at ion s o f protectedhealth information ab o u t the individual.
C. The individual retains the right to inspect and copy protected health information about theindividual except for the following:i) psychotherapy notesii) information c o m p i l e d in reasonable a n t i c i p at i o n o f , or for use in, a civil, criminal or
administrative a c t i o n or proceeding andiii) protected health information subject to the Clinical Laboratory Improvements Amendments
of 1988, to the extent the provision law or information would prohibit access to the individualexempt from the Clinical Laboratory Amendments of 1988.
D. The individual retains the right to amend protected health information so long as Hearts andHands retains such information. Hearts and Hands retains the right to deny an individual’srequest to amend protected health information if it determines:i) that the information to be amended was not created by Hearts and Hands, unless the
individual provides a reasonable basis to believe that the originator of the protected healthi n f o r m a t i o n is no longer available to act on the requested amendment:
ii) the information sought to be amended is not part of the designated set of the individual’srecord: Hearts and Hands determines that the record or information sought is accurate andcomplete.
E. The individual retains the right to receive an accounting of disclosures of protected healthinformation made within six (6) years prior to the date on which the accounting is requestedexcept for disclosures:i) Made to carry out treatment, payment and health care operations.ii) Made to an individual upon that individual’s request of protected health information about
that individual.iii) Made incident to a use or disclosure otherwise permitted or required by law.iv) Made pursuant to an authorization provided but not in the Notice.v) Made for the facility’s directory or to persons, such as an individual’s care or otherwise
entitled to notification.vi) Made for national security or intelligence purposes.vii) Made to correctional institutions or law enforcement official.
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viii) Made as part of a limited date set that does not contain identifying information regarding theindividual: or
ix) Made prior to the effective compliance date of Hearts and Hands original notice.F. The individual including any individuals who have agreed to receive the Notice electronically,
retain the right to obtain a copy of the Notice from Hearts and Hands upon request.G. Hearts and Hands is required by law to maintain the privacy of protected health information and
to provide individuals with notice of its legal duties and privacy practices with respect toprotected health information.
H. Hearts and Hands is required to abide by the terms of the Notice currently in effect.I. Hearts and Hands reserves the right to change the terms of its notice and to make the new
notice and provisions effective for all protected health information that it maintains. In theevent that Hearts and Hands seeks to apply a change in a privacy practice that is described inthe Notice to protect health information that Hearts and Hands created or received prior toissuing a revised notice, Hearts and Hands shall provide individuals with a revised notice byhandout or mail.
J. Individuals may complain to Hearts and Hands and to the Secretary of Health and HumanServices if they believe their Privacy rights have been violated. If an individual chooses to file acomplaint with Hearts and Hands, he/she may do so in the following manner: writtencomplaint/notice. The individual will not be retaliated against for filing a complaint.
K. If the individual desires further information co n cern in g h is/her privacy rights under thisNotice, they may contact
Hearts and Hands Therapy Services, Inc 1-844-543-8437
2001 Professional Pkwy, Woodstock, GA 30188.
L. This Notice first went into effect on the 1st Day of May 2008. This date is not earlier than thedate on which the Notice has been printed or otherwise published.
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2001 Professional Pkwy Suite 220 Woodstock, GA 30188