CONSENT FOR TREATMENT

I hereby authorize Personal Care Medical Group. LLC d/b/a Glades Medical Centers, the attending physician, or the physician designated by them and other employees to examine and treat me. I also authorize such treatment and procedures as deemed necessary by the physician, including but not limited to the taking of X-Rays, medications, blood samples, urine samples and other treatments or procedures not listed.

I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantee or assurance has been made or implied to me as to the results that may be obtained by examination and treatment.

CONSENT FOR PURPOSES OF TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

I consent to the use or disclosure of my protected health information by Glades Medical Centers for purposes of diagnosing or providing treatment to me, obtaining payment for my health care bills, to conduct health care operations of Glades Medical Centers, including disclosing my protected health information with Glades Medical Centers, Business Associates. I consent to the marketing and sale of my protected health information in accordance with federal and state laws. I understand that diagnosis or treatment of me by Glades Medical Centers, is conditioned upon my consent as evidenced by my signature on this document.

My «protected health information» means health information and, for purposes of this document, personal information. Protected health information includes my demographic information, collected from me and created, received or stored by my physician, another health care provider, a health plan, or my employer. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is reasonable basis to believe the information may identify me.

I understand I have a right to review the Glades Medical Centers, Notice of Privacy Practices prior to signing this document which is included in these documents. The Glades Medical Centers, Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of use and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the activities of health care operations of Glades Medical Centers, The Notice of Privacy Practices can be provided at any of our locations, please ask the receptionist for a copy. This Notice of Privacy Practices also describes my rights and the duties of Glades Medical Centers, with respect to my protected health information. Glades Medical Centers reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.

I may obtain a revised Notice of Privacy Practices by requesting in writing from Glades Medical Centers or asking for one at the time of my next appointment.

FINANCIAL RESPONSIBILITY

I understand that insurance billing is a service provided as a courtesy and that I am at all times financially responsible to Glades Medical Centers and for any charges not covered by my healthcare benefits. Payments for services are due at the time services are rendered, unless a payment arrangement has been approved. Glades Medical Centers accepts checks, cash, and credit cards. It is my responsibility to notify Glades Medical Centers of any changes in my healthcare coverage. I am responsible for the entire bill or balance of the bill as determined by Glades Medical Centers, and/or my healthcare insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payments in regard to medical services.

ASSIGNMENT OF BENEFITS

I authorize direct remittance of payment of all insurance benefits, including Medicare, if I am a Medicare beneficiary, to Glades Medical Centers for all covered medical services during treatment and care provide by Glades Medical Centers and/or its affiliated entities or otherwise at its direction. I understand and agree this Assignment of Benefits will constitute a continuing authorization, maintained on file with Glades Medical Centers, which will authorize and all for direct payment to Primary Care Physicians of all applicable and eligible insurance benefits for all subsequent and continuing treatment, services and/or care provided to me by Glades Medical Centers.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Glades Medical Centers and its employees are dedicated to maintaining the privacy of your personal health information («PHI»), as required by applicable federal and state laws. These laws require us to provide you with this Notice of Privacy Practices, and to inform you of your rights and our obligations concerning Protected Health Information, or PHI, which is information that identifies you and that relates to your physical or mental health condition. We are required to follow the privacy practices described below while this Notice is in effect.

1. Permitted Disclosures of PHI. We may disclose your PHI for the following reasons:
  • Treatment: We may disclose your PHI to a physician or other health care provider providing treatment to you. For example, we may disclose medical information about you to physicians, nurses, technicians, or personnel who are involved with the administration of your care.
  • Payment: We may disclose your PHI to bill and collect payment for the services we provide to you. For example, we may send a bill to you or to a third-party payor for the rendering of services by us. The bill may contain information that identifies you, your diagnosis and procedures and supplies used. We may need to disclose this information to insurance companies to establish insurance eligibility benefits for you. We may also provide your PHI to our business associates, such as billing companies, claims processing companies and others that process our health care claims.
  • Health Care Operations: We may disclose your PHI in connection with our health care operations. Health care operations include quality assessment activities, reviewing the competence or qualifications of health care professionals, evaluating provider performance, and other business operations. For example, we may use your PHI to evaluate the performance of the health care services you received. We may also provide your PHI to accountants, attorneys, consultants and others to make sure we comply with the laws that govern us.
  • Emergency Treatment: We may disclose your PHI if you require emergency treatment or are unable to communicate with us.
  • Family and Friends: We may disclose your PHI to a family member, friend, or any other person who you identify as being involved with your care or payment for care, unless you object.
  • Required by Law: We may disclose your PHI for law enforcement purposes and as required by state or federal law. For example, the law may require to report instances of abuse, neglect, or domestic violence to report certain injuries such as gunshot wounds; or to disclose PHI to assist law enforcement in locating a suspect, fugitive, material witness or missing person. We will inform you or your representative if we disclose your PHI because we believe you are a victim of abuse, neglect, or domestic violence, unless we determine that informing you or your representative would place you at risk. In addition, we must provide PHI to comply with an order in a legal or administrative proceeding. Finally, we may be required to provide PHI in response to a subpoena discovery request or other lawful process; but only if efforts have been made, by us or the requesting party, to contact you about the request or to obtain an order to protect the requested PHI.
  • Serious Threat to Health or Safety: We may disclose your PHI if we believe it is necessary to avoid a serious threat to the health and safety of you or the public.
  • Public Health: We may disclose your PHI to public health or other authorities charged with preventing or controlling disease, injury or disability, or charged with collecting public health data.
  • Health Oversight Activities: We may disclose your PHI to a health oversight agency for activities authorized by law. These activities include audits; civil, administrative or criminal investigations or proceedings; inspections; licensure or disciplinary actions; or other activities necessary for oversight of the health care system, government programs and compliance with civil rights laws.
  • Research: We may disclose your PHI for certain research purposes, but only if we have protections and protocols in place to ensure the privacy of your PHI.
  • Workers’ Compensation: We may disclose your PHI to comply with laws relating to workers’ compensation or other similar programs.
  • Specialized Government Activities: If you are active military or a veteran, we may disclose your PHI as required by military command authorities. We may also be required to disclose PHI to authorized federal officials for the conduct of intelligence or other national security activities.
  • Organ Donation: If you are an organ donor, or have not indicated that you do not wish to be a donor, we may disclose your PHI to organ procurement organizations to facilitate organ, eye or tissue donation and transplantation.
  • Coroners, Medical Examiners, Funeral Directors: We may disclose your PHI to coroners or medical examiners for the purposes of identifying a deceased person or determining the cause of death, and to funeral directors as necessary to carry out their duties.
  • Disaster Relief: Unless you object, we may disclose your PHI to a governmental agency or private entity (such as FEMA or Red Cross) assisting with disaster relief efforts.
  • Direct Contact with You: We may use your PHI to contact you to remind you that you have an appointment, or to inform you about treatment alternatives or other health-related benefits and services that may be of interest to you.
2. Disclosures Requiring Written Authorization
  • Not Otherwise Permitted: In any other situation not described in Section 1 above, we may not disclose your PHI without your written authorization.
  • Psychotherapy Notes: We must receive your written authorization to disclose psychotherapy notes, except for certain treatment, payment or health care operations activities.
  • Marketing and Sale of PHI: We must receive your written authorization for any disclosure of PHI for marketing purposes or for any disclosure which is a sale of PHI.
3. Your Rights
  • Right to Receive a Paper Copy of This Notice: You have the right to receive a paper copy of this Notice upon request.
  • Right to Access PHI: You have the right to inspect and copy your PHI for as long as we maintain your medical record. You must make a written request for access to the Privacy Coordinator at the address listed at the end of this Notice. We may charge you a reasonable fee for the processing of your request and the copying of your medical record pursuant to Fla: Stat. 381.028(7)(c). In certain circumstances we may deny your request to access your PHI, and you may request that we reconsider our denial. Depending on the reason for the denial, another licensed health care professional chosen by us may review your request and the denial.
  • Right to Request Restrictions: You have the right to request a restriction on the use or disclosure of your PHI for the purpose of treatment, payment or health care operations, except for in the case of an emergency. You also have the right to request a restriction on the information we disclose to a family member or friend who is involved with your care or the payment of your care. However, we are not legally required to agree to such a restriction.
  • Right to Restrict Disclosure for Services Paid by You in Full: You have the right to restrict the disclosure of your PHI to a health plan if the PHI pertains to health care services for which you paid in full directly to us.
  • Right to Request Amendment: You have the right to request that we amend your PHI if you believe it is incorrect or incomplete, for as long as we maintain your medical record. We may deny your request to amend if (a) we did not create the PHI, (b) is not information that we maintain, (c) is not information that you are permitted to inspect or copy (such as psychotherapy notes), or (d) we determine that the PHI is accurate and complete.
  • Right to An Accounting of Disclosures: You have the right to request an accounting of disclosures of PHI made by us (other than those made for treatment, payment or health care operations purposes) during the 6 years prior to the date of your request. You must make a written request for an accounting, specifying the time period for the accounting, to the Privacy Coordinator at the address listed at the end of this Notice.
  • Right to Confidential Communications: You have the right to request that we communicate with you about your PHI by certain means or at certain locations. For example, you may specify that we call you only at your home phone number, and not at your work number. You must make a written request, specifying how and where we may contact you, to the Privacy Coordinator at the address listed at the end of this Notice.
  • Right to Notice of Breach: You have the right to be notified if we or one of our business associates become aware of a breach of your unsecured PHI.
4. Changes to this Notice

We reserve the right to change this Notice at any time in accordance with applicable law. Prior to a substantial change to this Notice related to the uses or disclosures of your PHI, your rights or our duties, we will revise and distribute this Notice.

5. Acknowledgement of Receipt of Notice

We will ask you to sign an acknowledgment that you received this Notice.

6. Questions and Complaints

If you would like more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made regarding the use, disclosure, or access to you PHI, you may complain to us by contacting the Privacy Coordinator at the address and phone number at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file such a complaint upon request.

We support your right to the privacy of your PHI. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Please direct any of your questions or complaints to:

  • Privacy Officer: Josh M. Bloom, 1 NE 167th St, North Miami Beach, FL 33162
  • Effective Date: August 1, 2023.