Privacy, Rights, and Responsibilities
Rights and Responsibilities
You have the right to receive information about the services, benefits,
practitioners, providers, member rights, and responsibilities, and clinical
guidelines.
• You have the right to be treated with respect, dignity, and privacy
regardless of race, gender, veteran status, religion, marital status, national
origin, physical disabilities, mental disabilities, age, sexual orientation, or
ancestry.
• You have the right to receive information in a manner and format that is
understandable and appropriate in any langua
You have the right to be free from restraint and seclusion as a means of
coercion, discipline, convenience, or retaliation.
• You have the right to have anyone you choose to speak for you in your
contact with us. You Have the right to decide who will make medical
decisions for you if you cannot make them.
• You have the right to refuse treatment, to the extent allowed by law.
• You have the right to be a part of decisions that are made about plans for
your care.
• You have the right to talk with your provider about the best treatment
options for your condition, regardless of the cost of such care, or benefits
coverage.
• You have the right to obtain information regarding your own treatment
record with a signed consent in a timely manner and have the right to
request an amendment or correction to your medical records.
• You have the right to a copy of your rights and responsibilities.
• You have the right to tell us what you think your rights and responsibilities
as a client should be.
• You have the right to exercise these rights without having your treatment
adversely affected in any way.
You have the right to make complaints (verbally or in writing) about staff,
services, or the care given by your provider or change m.f.c.r., inc. to any
governing body, our offices, and the offices of civil rights (OCR) by
contacting our offices to report complaint to the offices or (ocr) filed in
writing by mail, fax, e-mail, or via the OCR Complaint Portal.
By mail:Print and mail the completed complaint and consent forms to:
Centralized Case Management Operations
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201
。 Portal:HHS.gov or https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf
email: OCRComplaint@hhs.gov
You have the right to have all communication regarding your health information kept
confidential by staff and contracted providers and practitioners to the extent required
by the law.
• You have the right to know about covered services, benefits, and your health care
and how to seek these services. You have the right to receive timely care consistent
with your needs for care
Responsibilities
· You have the right to know the facts about any changes or bill you receive.
You have the responsibility to provide information to the best of your ability, that your
provider may need to plan your treatment.
You have the responsibility to learn about any change in your condition and work
with your provider to develop a plan for your care.
You have the responsibility to follow the plans and instructions for care you have
agreed to with your provider.
Notice of Privacy Practices
AA Compliance Patient Consent Form Our Notice of Privacy Practices provides information
about how we may use or disclose protected health information. The notice contains a patient's
rights section describing your rights under the law. You ascertain that by your signature that you
have reviewed our notice before signing this consent. The terms of the notice may change, if so,
you will be notified at your next visit to update your signature/date. You have the right to restrict
how your protected health information is used and disclosed for treatment, payment or
healthcare operations. We are not required to agree with this restriction, but if we do, we shall
honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996)
law allows for the use of the information for treatment, payment, or healthcare operations. By
signing this form, you consent to our use and disclosure of your protected healthcare
information and potentially anonymous usage in a publication. You have the right to revoke this
consent in writing, signed by you. However, such a revocation will not be retroactive. By signing
this form, I understand that: Protected health information may be disclosed or used for
treatment, payment, or healthcare operations. The practice reserves the right to change the
privacy policy as allowed by law. The practice has the right to restrict the use of the information
but the practice does not have to agree to those restrictions. The patient has the right to revoke
this consent in writing at any time and all full disclosures will then cease. The practice may
condition receipt of treatment upon execution of this consent.
e may use phone, email, or send a text to you to confirm appointments.
• We may leave a message on your answering machine at home or on your cell phone.
• We will not discuss your medical condition with any member of your family unless you
direct and authorize us to do so. To authorize the sharing of information please advise
our offices or counselors so we can send you the form to do so.
your right to change and manage the way your information is used and/or communicated. If
you would like to opt out of any form of communication or would like to add a person in which to
share or discuss your medical condition and or information please advise your counselor or our
offices so we may send you a form to fill and sign. This will be updated on your file and we will
act accordingly.