HIPAA Privacy Practices and Consent Form
Right to Notice : As a patient, you have the right to adequate notice of the uses and disclosures of your protected health information. Under the Heath Insurance Portability and Accessibility Act (HIPAA), Physicians, Athletic Trainers, and the MSU Coaching Staff involved with your sport, Physical Therapists, Occupational Therapists, and other pertinent health care providers in association with MSU Athletic Training, including MSU Student Health Services, the Orthopaedic and Fracture Clinic, PA, Mankato Clinic Health System, Immanuel St. Joseph's Health System, and Prosthetic Laboratories can use your protected health information for treatment, payment and health care operations.
Treatment - We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. (please initial) Payment - We may use and disclose your health information to/from the above listed providers, AG (MSU secondary/excess insurance policy, and your primary insurance carrier to aid in obtaining treatment information and payment for services provided to you. (please initial) Health care operations - We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include, health/medical insurance communications for explanation of benefits, quality assessment and improvement activities, reviewing the competency or qualifications of healthcare professionals, evaluating provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. (please initial)
Your Authorization : Most uses and disclosures that do not fall under treatment, payment, health care operations will require your written authorization. Upon signing, you may revoke your authorization (in writing) through our practice at any time.
Emergency Situations : In the event of your incapacity or an emergency situation, we will disclose health information to a family member, or another person responsible for your care, using our professional judgment. We will only disclose health information that is directly relevant to the person's involvement in your healthcare.
Marketing : We will not use your health information for marketing communications without your written authorization.
Required by Law : We may also use or disclose your health information when we are required to do so by law.
Abuse or Neglect : We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to you or other people's health or safety.
National Security : We may disclose the health information of Armed Forces personnel to military authorities under certain circumstances. We may disclose health information to authorized federal officials required for lawful intelligence, counterintelligence and other national security activities. We may disclose health information of inmates or patients to the appropriate authorities under certain circumstances.
Appointment Reminders : We may use or disclose your health information to provide you with appointment reminders via phone, email or letter.
Your Right as a Patient : You have the right to restrict the disclosure of your protected health information (in writing). The request for restriction may be denied if the information is required for treatment, payment or health care operations. - You have the right to receive confidential communications regarding your protected health information. -You have the right to inspect and copy your protected health information. -You have the right to amend your protected health information. -You have the right to receive an account of disclosures of your protected health information. -You have the right to a paper copy of this notice of privacy practices. (please initial)
Legal Requirements : MSU Athletic Training, and it's Health Care Associates are required by law to maintain the privacy of your protected health information. We are required to abide by the terms of this notice as it is currently stated, and reserve the right to change this notice. The policies in any new notice will not be in effect until they are posted to this notice, or are available within our office.
Complaints : If you have complaints regarding the way your protected health information was handled, you may submit a complaint in writing to our office. You will not be retaliated against in any manner for a complaint.
I acknowledge by my signature that my PHI (protected health information) may be used or disclosed as stated above, realizing that I have the right to a written formal complaint, a right to knowledge of my information disclosures, as well as the other rights stated above. I acknowledge that I have read these rights stated and have read the privacy rules of MSU Athletic Training.
