Liz,

Here is something I was working on this afternoon. It's in the infancy stage but maybe we can come up with something together we can all use.

I have the original document in MS Word 2000 and Wordperfect 10.

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ABC Medical Clinic
123 Main Street
North Miami Beach, Florida 33169


May 8, 2001

To: Emergency Department Patient

Subject: Health Insurance Portability and Accountability Act (HIPAA) Privacy Regulation Consent Form.


On April 14, 2001, the Privacy Regulation of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 went into effect, requiring the protection of the confidentiality of your health information. We require your consent, in nearly all situations, involving the disclosure of your personal health information (PHI). Please make sure you read all of the information contained on this consent form before you sign it.

As your emergency department provider, I do not work for the hospital where you are being treated. The services I am providing to you are separate than that provided by the hospital. I will be billing you separately from the hospital, or, per your request, I will be sending a claim to your insurance carrier for the medical debt you are incurring today. Please understand that even though you have health insurance, you are legally responsible for ensuring this debt is paid.

In order to provide you with the care and treatment you have requested, I do not do the medical billing myself. I contract with a third-party medical billing company that also has access to your personal health information. They use this information so they can medically code your visit. This information is placed on a claim form so they can send the claim to your insurance carrier, or, if you have no insurance, they will send you a bill.

The billing company sends the claim to your insurance carrier by paper or by modem to an electronic clearinghouse. The clearinghouse then sends the claim to your insurance carrier. This is accomplished electronically via secure means. The third party medical billing company may also receive requests for your personal health information from other outside sources such as your insurance carrier or an attorney that you may have hired. Failure to allow this information to be released may result in a denial of your medical claim, which will cause you to pay for the medical bill yourself.

If your medical debt becomes delinquent, the billing company may send your account to a professional collection agency in order to collect the debt that is owed. The collection agency will also have access to your personal health information based on the data contained in your billing record.

The billing company, collection agency, and the clearinghouse, have all signed confidentiality agreements stating your personal health information will not be discussed or released without a signed consent form, from you, allowing them to release this information. Every employee of the billing company, clearinghouse, and collection agency, has signed a similar document. Requests for personal health information that come from your insurance carrier or attorney will not be processed without a written request from them and your written consent. At NO time, will your personal health information, or billing information, be discussed over the telephone or via the internet through websites or e-mail. This includes telephone calls allegedly from you. We will not discuss your private health information with spouses, relatives or parents of children over the age of 18 years old without written consent and then we will only respond in writing.

If you refuse the billing company access to your personal health information, this will cause your medical claim to go unprocessed and you will be responsible for paying your medical debt yourself. Even if you refuse to allow the billing company access to your personal health information, we have the right to deny your request.

You are entitled to other certain rights, which will be addressed on this consent form. Even though you can make certain requests regarding the access of your health information, these requests may be denied at any time.

Your consent is required in nearly all situations involving the disclosure of your personal health information. This consent includes marketing, fund-raising, and underwriting. Your consent is not required for research, law enforcement purposes, judicial proceedings, and public health activities.

You have the right to request restrictions as to whom your personal health information is released to. For example, you may ask me not to disclose any of your personal health information to your sister, but, as stated earlier, we do not have to grant your request.

You do have the right to your own personal health information and access to any disclosures of your personal health information. All you have to do is submit this request, in writing, to my office. The fee for this is $15 per request. Within 30 days of receipt of your written request and payment, the information will be sent to you. Any other requests for your personal health information will be placed on file and recorded in your medical billing records.

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Signed Authorization

I and or my guarantor _______________________________________, have read this document and I have been informed of my rights to the privacy of my personal health information under the HIPAA Privacy Regulation, by Emergency Medicine Specialists.

I or my guarantor, do hereby authorize Emergency Medicine Specialists, it’s representative billing company(s), health claims clearinghouse, and collection agency, full access of my personal health information for the purposes of medical coding and billing and debt collecting.

I fully understand that this medical debt is my or my guarantor’s responsibility and I or my guarantor will do everything to ensure payment of my medical debt to the provider.

My or my guarantor’s signature allows the release of my personal health information to my attorney or health insurance carrier only upon written receipt of a request for this information and this request also has provisions to protect my personal health information. My signature also allows the provider or his/her representative to file a complaint with the Insurance Commissioner, on my behalf, against my insurance carrier, in the event my medical claim is not paid within the time frame allowed under Florida Law.

I understand that all requests for my personal health information will be documented.

I understand that even though I may request restrictions on disclosures to others of my personal health information, my request may be denied.

I understand that I have a right to a copy of my personal health information, and an accounting of all disclosures of my personal health information and I must make this request in writing. A copy will be sent to me within 30 days of receipt of my request. I also understand there is a $15 fee for copying, postage, and processing of the personal health information and this fee must be paid in advance.

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Patient Signature Date

_____________________________________________
Guarantor Signature Date

_____________________________________________
Witness Signature        Date

_____________________________________________
Witness Signature                Date


(c) Steven Verno 2001