Notice of Privacy Practices

Effective March 22, 2020

Privacy Practices

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.  

We are required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices with respect to protected health information. We are required to abide by the terms of this notice for as long as it is in effect. 

If you have any questions regarding this notice, please contact: 
Janice Clauer, HIPAA Privacy and Security Officer
Corporate Compliance Office
Nuvance Health
14 Research Drive
Bethel, Connecticut 06801 
Compliance & Privacy Help Line at (844) 650-1212

WHO WILL FOLLOW THIS NOTICE  

  • Nuvance Health (the “Entity”) is, along with the affiliated providers listed on Appendix A, a member of Nuvance Health. The Entity, including the following workforce members, will follow the privacy practices set forth in this Notice: 
  • Any health care professional on our medical or allied practitioner staff.
  • All departments and units of the Entity. 
  • Any member of a volunteer group authorized to help you while you are receiving services. 
  • All employees and staff and other personnel. 
  • The Entity may share information with the other Nuvance Health affiliated entities include the entities listed in Appendix A, which are also bound by the terms of this Notice, for purposes permitted under applicable law. 

OUR PLEDGE REGARDING MEDICAL INFORMATION  

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all the records of your care whether made by Entity personnel or your personal doctor at an Entity Site. “Entity Site” means the Entity’s location where you receive health services. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your medical information created in the doctor’s practice. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. The Law requires us to: 

  • Make sure that medical information that identifies you is kept private. 
  • Give you this notice of our legal duties and privacy practices with respect to medical information about you. 
  • Follow the terms of the notice that is currently in effect. 

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU  

The following categories describe different ways that we use and disclose medical information, which do not require your written authorization. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the following categories: 

For treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. A doctor at the hospital may share your health information with another doctor inside our hospital, or with a doctor at another hospital, to determine how to diagnose or treat you. Your doctor may also share your health information with another doctor to whom you have been referred for further health care. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate dietary teaching. Different departments of the Entity also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside of the Entity who may be involved in your medical care after you leave our care, such as family members, clergy or others we use to provide services that are part of your care. 

For payment. We may use and disclose medical information about you so that the treatment and services you receive at the Entity may be billed to and payment may be collected from you, an insurance company or a third party. For example we may need to give your health plan information about the services you received while under our care so your health plan will pay us or reimburse you. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. 

For healthcare operations. We may use and disclose medical information about you for Entity healthcare operations, such as quality assessment and improvement activities, professional training programs, and legal compliance programs. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. These uses and disclosures are necessary to run the Entity and make sure that all of our patients receive quality care. 

Business Associate. We may disclose your medical information to third-party business associates that we contract with to perform certain business functions or provide certain business services on our behalf, such as auditing, billing, legal services, etc. For example, we may use another company to perform medical billing services. All of our business associates are required to maintain the privacy and confidentiality of your medical information. In addition, at the request of your other health care providers or health plan, we may disclose your medical information to their authorized business associates for purposes of performing certain business functions or health care services on their behalf. For example, we may disclose medical information to a business associate of Medicare for purposes of medical necessity review and audit. 

Appointment reminder. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care. 

Treatment alternative. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-related benefits and services.  We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you. 

Fundraising activities. We may use medical information about you to contact you in an effort to raise money for the Entity and its operations. We may disclose patient contact information to a foundation related to the Entity so that the foundation may contact you in raising money. We only would release contact information, such as your name, address and phone number, the dates you received treatment or services, the department which treated you, your treating physician, and your medical outcomes. You have the right to opt-out of receiving fundraising communications. Any fundraising communication sent to you will let you know how you can opt-out of receiving similar communications in the future, or you may opt-out of receiving fundraising communications by sending your name and address to the foundation related to the Entity, together with a statement that you do not wish to receive fundraising materials or communications from us. Your treatment or payment will not be conditioned on your choice with respect to the receipt of fundraising communications. 

Entity directory.  We may include certain limited information about you in the Entity directory while you are a patient, unless you object. This information may include your general demographic information such as your age and gender, as well as your diagnosis, general condition, attending physician, the service or services you are receiving, and your religious affiliation. This directory information, except for your religious affiliation, may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if he or she doesn’t ask for you by name. 

Individuals involved in your care or payment for your care:  We may release medical information about you to a friend or family member who is involved in your medical care, unless you object or the law does not allow it. For example, there is a state law that prohibits us from informing the parents or guardians of a minor that the minor has a venereal disease or has had an abortion. There is also a law with special rules for disclosing HIV and AIDS-related information. We may also give information to someone who helps pay for your care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. 

Research. Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. Before we use or disclose medical information for most types of research, the project must be approved through a research approval process. We may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the agency/Entity. We also may contact you about possible research opportunities. Except in certain very limited circumstances such as described above, we will ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care. 

As required by law.  We will disclose medical information about you when required to do so by federal, state or local law. 

To avert a serious threat to health or safety.   We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. An example of a serious threat is a serious and contagious disease. 

Special situations: 

Emergencies.  We may use or disclose your health information if you need emergency treatment or if we are required by law to treat you but are unable to obtain your consent. If this happens, we will try to obtain your consent as soon as we reasonably can after we treat you. 

Communication Barriers.  We may use and disclose your health information if we are unable to obtain your consent because of substantial communication barriers, and we believe you would want us to treat you if we could communicate with you. 

Organ and Tissue Donation.   If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. 

Military and Veteran.  If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. 

Workers’ compensation.  We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work related injuries or illnesses. 

Public health risks.  We may disclose medical information about you for public health activities. These activities generally include the following: 

  • To prevent or control disease, injury or disability; 
  • To report births and deaths; 
  • To report child abuse or neglect; 
  • To report reactions to medications or problems with products; 
  • To notify people of recalls of products they may be using;
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and
  • To notify appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. 

Health Regulatory Agencies.  We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws. 

Lawsuits and disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law enforcement. We may release medical information if asked to do so by a law enforcement official: 

  • In response to a court order, subpoena, warrant, summons or similar. 
  • To identify or locate a suspect, fugitive, material witness, or missing person. 
  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement. 
  • About a death we believe may be the result of criminal conduct. 
  • About criminal conduct at the hospital. 

In emergency circumstances to report a crime; the location of the crime or victim; or the identity, description or location of the person who committed the crime. 

Coroners, medical examiners, and funeral directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the hospital to funeral directors as necessary to carry out their duties. 

National security and intelligence activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law. 

Protective services for the President and others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations. 

Inmates-information released to correctional institution. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. 

USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION WHICH REQUIRE YOUR WRITTEN AUTHORIZATION  

Marketing. Your written authorization is required for us to use or disclose your medical information for marketing purposes, except if we communicate personally with you face-to-face or if we provide you with prescription refill reminders or otherwise communicate with you about a drug or biologic that you are currently prescribed and we do not in exchange receive any payment that is unreasonably related to our cost of making such communication to you. It is not considered marketing, and therefore your written authorization is not required, if we communicate with you related to your individual treatment, case management, or care coordination, or if we direct or recommend alternative treatment, therapies, healthcare providers or settings of care, unless we receive payment from a third-party in exchange for making such communication to you. If marketing activities are to result in payment to us from a third party we will state this on the authorization.  

Sale of Medical Information. Your written authorization is required for any use or disclosure which is considered a sale of your medical information. Any authorization for the sale of medical information will state that the disclosure will result in payment to us. 

Psychotherapy Notes. Your written authorization is required for any use or disclosure of psychotherapy notes, except: for use by the originator of the psychotherapy notes for treatment or health oversight activities; for use or disclosure for our own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; for use or disclosure to defend us in a legal action or other proceeding brought by you; to the extent required to investigate or determine our compliance with the applicable law; to the extent that such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of such law; for health oversight activities with respect to the oversight of the originator of the psychotherapy notes; for disclosure to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law; or if disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and is made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU  

You have the following rights regarding medical information we maintain about you: 

Right to inspect and copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. This does not include psychotherapy notes or information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Entity’s Medical Records department. If you request a copy of the information, we will act on your request within 30 days, unless we need an extension of that time. We may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the Entity will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. 

Right to amend. You have the right to request an amendment of your health information for as long as the information is kept by or for the Entity. Your amendment request must be made in writing and submitted to the Medical Records department. We may deny your request if you ask us to amend information that: 

  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; 
  • Is not part of the medical information kept by or for the Entity; 
  • Is not part of the information which you would be permitted to inspect and copy; or 
  • Is accurate and complete. 

Right to accounting of disclosures. You have the right to request an accounting, or list, of certain disclosures we have made of your information within the last 6 years. To request this list or accounting of disclosures, you must submit your request in writing to the Entity’s Medical Records department. Your request must state a time period, which may not be longer than six years and may not include dates prior to April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We must act on your request within 60 days of when we receive it, but we can request an extension of time if we tell you the reason for the delay.

Right to request restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you for purposes of maintaining an Entity directory. For example, you could ask that we not use or disclose information about your location in the hospital or your religious affiliation. We are required to comply with a request that we not disclose your health information to a health plan for payment or health care operations purposes, if the health information pertains to a health care item or service for which we have been involved and you have paid for the item or service in full out-of-pocket. For all other requests, we will consider your requested restriction but WE ARE NOT REQUIRED TO AGREE WITH YOUR REQUEST. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the Entity’s Medical Records department. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to request confidential communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Entity’s Medical Records department. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. 

Right to a paper copy of this notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our website at: www.health-quest.org. 

HEALTH INFORMATION EXCHANGE  

We may store your health records electronically with Taconic Health Information Network and Community (THINC) and/or the New York eHealth Collaborative (NYeC). If you sign a separate written consent, or in limited emergency circumstances, other health care providers will be able to access your information from THINC or NYeC for the purpose of treating you. THINC and NYeC have implemented administrative, physical and technical safeguards to protect the confidentiality and integrity of your information.  

INFORMATION BREACH NOTIFICATION  

We will notify you in writing if we discover a breach of your unsecured health information, unless we determine, based on a risk assessment, that notification is not required by applicable law. You will be notified without unreasonable delay and no later than 60 days after discovery of the breach. Such notification will include information about what happened and what has been done or can be done to mitigate any harm to you as a result of such breach.  

CHANGES TO THIS NOTICE  

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice within the Entity. The notice will contain on the first page, in the top right hand corner, the effective date. The next time you come to an Entity to receive treatment, we will give you a copy of the current notice in effect.

Special Requirements and Rules Regarding Disclosure of Psychiatric, Substance Abuse, Genetic Testing and Hiv-related Information

Subject to some exceptions, state laws generally requires your consent to disclose your health information. For disclosures concerning health information relating to care for psychiatric conditions, substance abuse, genetic testing and HIV-related testing and treatment (“Sensitive Information”) special restrictions may apply. In general, Sensitive Information may not be disclosed without your written permission or a court order.

COMPLAINTS  

If you believe your privacy rights have been violated, you may file a complaint with the Entity by contacting the Office of Corporate Compliance, Internal Audit & Privacy at (844) 650-1212; or placing your complaint in writing to the Department of Health and Human Services. We will not retaliate against you for filing a complaint. To file a written complaint contact: 

Nuvance Health
Corporate Compliance Office
Nuvance Health
14 Research Drive
Bethel, Connecticut 06801 
(844) 650-1212

U.S. Department of Health and Human Services 
Office for Civil Rights 
Jacob Javits Federal Building 
26 Federal Plaza – Suite 3312 
New York, New York 10278 

OTHER USES AND DISCLOSURES OF MEDICAL INFORMATION  

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. You may revoke this written permission, in writing, at any time. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. We are also unable to take back an y disclosure if the authorization was obtained as a condition of obtaining insurance coverage, where there is other applicable law that provides the insurer with the right to contest a claim under the policy or the policy itself.

APPENDIX A  

NUVANCE HEALTH PROVIDERS  
FACS, LLC 
Health Quest Medical Practice, P.C. 
Health Quest Urgent Medical Care Practice, P.C. 
Hudson Valley Cardiovascular Practice, P.C. 
Hudson Valley Emergency Medicine, PLLC 
Hudson Valley Home Care, Inc. (Certified) 
Hudson Valley Home Care, Inc. (Licensed) 
Hudson Valley Newborn Physician Services, PLLC 
Mid-Hudson Radiation Therapists, Inc. 
Northern Dutchess Hospital 
Northern Dutchess Residential Health Care Facility, Inc. a/k/a. Thompson House 
Physicians Network, P.C. 
Putnam Hospital Center 
Riverside Physical and Occupational Therapy and Speech Pathology, PLLC d/b/a. Therapy Works 
Ulster Radiation Oncology Center 
Vassar Brothers Hospital d/b/a Vassar Brothers Medical Center
Eastern New York Medical Services, PC;
The Danbury Hospital (including its New Milford Hospital campus)
The Norwalk Hospital Association
Western Connecticut Home Care, Inc.
Western Connecticut Health Network Affiliates, Inc.
Western Connecticut Medical Group, Inc.


WESTERN CONNECTICUT MEDICAL GROUP, INC. (“WCMG”),
EASTERN NEW YORK MEDICAL SERVICES, P.C. (“ENYMS”),
HEALTH QUEST MEDICAL PRACTICE, P.C. (“HQMP”) &
HUDSON VALLEY CARDIOVASCULAR PRACTICE, P.C. (“HVCP”)
(WCMG, ENYMS, HQMP AND HVCP ARE COLLECTIVELY REFERRED TO HEREIN AS THE “PRACTICES”)
AUTHORIZATIONS FOR BASIC EXAMINATION AND TREATMENT,
CONDITIONS OF EXAMINATION AND TREATMENT, AND
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

No Alterations; Failure to Sign & Financial Responsibility.  This form may not be altered by the patient in any manner. Please understand that we cannot track individual changes, and therefore cannot honor cross-outs or new language. If you have questions about this form, please discuss them with the Practices’ staff, who will answer them to the best of their ability. Please also be aware that, if you do not sign this authorization, and this results in a refusal of your insurance company, managed care organization or any other third party payor to provide coverage and/or pay your Practice bill, you will be personally responsible for the entire unpaid portion of your bill. 

Authorization to Examine, Provide Treatment, and Perform Diagnostic Procedures Other Than Procedures Requiring Informed Consent. To the extent that specific authorization is required by law, I authorize the performing of all examinations, treatments, and care provided to me under the general or specific instructions or direction of my physician or the Practices staff. I also understand that by the fact of my seeking diagnosis and/or treatment from the Practices, routine examination, treatment, and care generally may be provided to me without specific authorization.

Informed Consent. I understand that if I require an operation, procedure or treatment involving a degree of risk requiring an informed consent, except in the event of emergency, my physician (or another Practice provider) will discuss with me the risks, benefits, and alternatives, answer my questions, and obtain my consent. I am entitled to consent or refuse to consent.

Students, Residents and Fellows. Medical, nursing and other health care students, as well as resident physicians (medical school graduates participating in post-graduate programs and training in a specialized area of medicine) and fellows (physicians who have completed residency and are receiving additional training in a specialized area of medicine) and medical researchers, provide or observe services provided to the Practices patients, and may be present during and/or participate in my routine treatment, operations, and special procedures as part of their research, or training and learning experiences.

Use of Your Protected Health Information for Treatment Payment, or Health Care Operations, or for Other Lawful Purposes. The Practices will keep your health information confidential.  There are a number of circumstances, however, where the Practices are permitted to use and disclose medical records and other information about you and your health without your authorization, including for the purposes of treatment, payment and health care operations, and there are other circumstances where the Practices are required by law to use or disclose your health information.  These purposes are more specifically described in the Nuvance Health Notice of Privacy Practices.  The Practices utilize an electronic health record and this allows for the exchange of health care information electronically between health care providers such as other treating or consulting doctors, other providers, and hospitals. The Practices also utilize an electronic prescription (“ePrescribe”) system to facilitate your treatment. In using the ePrescribe system, the Practices and its physicians and staff will receive prescription history from third parties, such as other health care providers and pharmacies, as well as submitting prescriptions. This information will support the Practices’ physicians and staff in avoiding drug duplication and drug interactions.  The Practices is dedicated to providing high-quality primary care and mental health services to our patients. To do that it is important that your providers work together. Therefore, Behavioral Health and Psychiatric records may be disclosed to your other treating or consulting providers on a need-to-know basis and in accordance with state and federal law.

Communication Via Telephone/Text Message.  By providing a contact phone number to the Practices, I hereby authorize Nuvance Health (including the Practices as well as all of Nuvance Health’s affiliated hospitals), along with their respective employees, agents, and business associates, to contact me at that number, via telephone and/or text message for any reason, including, without limitation, automated notifications, appointment reminders, billing, and debt collection.  Text messaging (for example, of automated notifications and/or appointment reminders) is provided by Nuvance Health free of charge; however, standard messaging rates from your mobile carrier may apply. You are not required to agree to this section in order to receive services from the Practices, and you may opt-out of being contacted by text message at any time by following the instructions provided in the message.

Authorization to Pay Benefits From Third Party Payment Sources; Financial Obligations. I authorize third party payors (which for purposes of this form include insurance companies, managed care organizations, Medicare, Medicaid and other governmental payors, and employer-sponsored health benefit plans), to make payment directly to the Practices, its affiliates, and any physicians involved in my care for medical services that it provides to me/the patient, and assign to the Practices any/all medical benefits (Group or Direct) otherwise payable to me/the patient. I understand and agree that I am financially responsible for payment of (i) all co-payments, co-insurance, and deductibles, (ii) all medical services provided by the Practices that are not covered by such payors, and (iii) all costs of collection of any delinquent balance, including but not limited to reasonable attorneys’ fees, which may be added to my/the patient’s account.  Without limitation of the foregoing sentence, I understand and agree that if the Practices do not have a participating provider agreement or other contract directly with my/the patient’s third party payor(s), then by accepting this authorization, the Practice are not agreeing to accept the reimbursement payable by such payor(s) as payment in full for the medical services it provides to me/the patient; the Practices retain the right to balance bill me for the difference between its charges for their services and the amount actually paid to the Practices by such payor(s) for such services, and I agree to be responsible for that amount.  No provision of any of my payors’ Plan Documents that is intended or could be deemed to waive, or otherwise prevent or limit, the Practices’ right to balance bill me will be binding on the Practices.  I further understand and agree that neither the Practices’ negotiation, endorsement or deposit of a check from me/the patient or any of my/the patient’s payors that is marked “Payment in full” (or anything similar), nor the Practices’ receipt of an Explanation of Benefits (EOB) that states “Payment in full” (or anything similar), will be deemed an “accord and satisfaction.”  I understand and agree that my/the patient’s refusal to grant authorization to my third party payors will in no way jeopardize my/the patient’s right to obtain present or future treatment except where disclosure is necessary for treatment, but understand and agree that under such circumstances I will be responsible for paying my/the patient’s bill in full.

Acknowledgement of Receipt of Notice of Privacy Practices. I acknowledge that I have received a copy of the Nuvance Health Notice of Privacy Practices (HIPAA).

MEDICARE PATIENTS ONLY
Medicare One-time Payment Authorization Applicable to Current or Future Treatment.

I request that payment of authorized Medicare benefits be made either to me or on my behalf to the Practices for any services furnished me by any of the Practices’ physicians and/or advanced practice providers (physician assistants, nurse practitioners, advanced practice registered nurses). I authorize any holder of Medical Information about me to release to the Centers for Medicare and Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services.

I HAVE READ AND UNDERSTAND THE AUTHORIZATIONS, AGREEMENTS AND NOTICES SET FORTH IN THIS FORM, AND I AGREE TO SUCH AUTHORIZATIONS, AGREEMENTS, AND NOTICES

If this form has not been signed by the patient, please specify the signer’s relationship to the patient, and, if necessary, explain why the patient did not sign.  If signed by the Patient’s Representative, please print name and describe relationship to patient.