I, the patient or authorized representative of the patient, acknowledge that a copy of the Notice of
Privacy Practices was provided to me.
I, the patient or authorized representative of the patient, am voluntarily seeking medical treatment.
I consent to examination by the physician, nurse practitioner, nurse or other health care professionals in this clinic. I also consent to any medical procedures, x-ray, laboratory tests, or other health care services ordered by the health care team. I understand that I may refuse specific treatments or
procedures by informing the health care team.
I, the patient or authorized representative of the patient, authorize the Mississippi Center for
Advanced Medicine to release any medical information necessary to process payment of my claim.
I, the patient or authorized representative of the patient, authorize payment directly to the Mississippi
Center for Advanced Medicine for their fees. I understand and agree that if any part of my account is not paid by insurance, I am financially responsible.
I, the patient or authorized representative of the patient, agree that the facility or any other collection
or servicing agency or agencies retained by the facility to collect any money that I owe to the facility
may contact me by telephone, text message, email, or letter.
I authorize release of my personal information including medical treatment, scheduling and billing information to the individuals listed below.
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.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We will share medical information about you for purposes of treatment (such as sending medical information about you to your physician or to a specialist as part of a referral); to obtain payment for treatment (such as submitting information that identifies you and your diagnosis to a payer or Medicare); and to support health care operations (such as using information about you to assess the quality of care we have provided, utilization and patient satisfaction review).
We may use health information about you without your prior authorization for several other reasons. Subject to applicable law, we may give out medical information about you to other entities to carry out their duties for (a) public health purposes (such as births, deaths, public health surveillance); (b) abuse, neglect or domestic violence reporting;
(c) health oversight audits or inspections; (d) research studies; (e) coroners or medical examiner services; (f) funeral arrangements; (g) organ donation; (h) tracking of FDA-regulated products; (i) workers’ compensation purposes; and
(j) emergencies. We also disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders.
We also may contact you for appointment reminders, or to tell you about or recommend possible treatment options, alternatives, health-related benefits or services that may be of interest to you. We may contact you to support fundraising efforts and you have the ability to opt out of receiving such communications. We may disclose medical information about you to a friend or family member who is involved in your medical care, to others whom you designate as involved in your medical care, or to disaster relief authorities so that your family can be notified of your location and condition.
Before we make any use or disclosure of your protected health information for marketing purposes, any disclosure that constitutes a sale of your protected health information, or in any other situation not covered by this notice where we may wish to use or disclose medical information about you, we will ask for your written authorization. You can later revoke your authorization by notifying us in writing.
In most cases, when you submit a written request, you have the right to look at or get a copy of medical information that we use to make decisions about your care. We will provide you a form that you can complete to make the request. If you request copies of the information, however, we may charge a fee for cost of copying, mailing or other related supplies. If we deny your request to review or obtain a copy, you may submit a written request for a review of that decision.
If you believe that information in our records about you is incorrect or if important information is missing, you have the right to request that we amend the records, by submitting a request in writing and including your reason for requesting the amendment. We will provide you a form that you can complete to make the request. We may deny your request to amend a record if the information was not created by us; if it is not part of the medical information maintained by us; or if we determine the record is complete and accurate. If we deny your request to amend, you may submit a written request to review that denial. You have the right to make a written request to us for a list of those instances where we have disclosed medical information about you, other than for treatment, payment, health care operations or where you specifically authorized a disclosure. Your request must state the time period desired for the accounting, which must be less than a 6-year period starting after April 14, 2003. The first disclosure list request in a 12-month period is free; other requests will be charged according to our cost of producing the list. We will inform you of the cost before charging you.
You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to communicate with you.
You have the right to restrict us from disclosing medical information about you to a health plan when you pay out of pocket in full for the health care item or service.
You may request, in writing, that we not use or disclose medical information about you for treatment, payment or healthcare operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency. We will consider your request but our processes may not be able to accommodate it and we are not legally required to agree to your request. We will inform you of our decision on your request.
All written requests or requests for review of denials should be submitted to our Privacy Officer identified at the bottom of this notice.
If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our Privacy Officer (listed below), or you may send a written complaint to the U.S. Department of Health and Human Services, Office of Civil Rights. Our Center Privacy Officer can provide you the address. Under no circumstance will you be penalized or retaliated against for filing a complaint.
Privacy Officer: Jordan Robinson, JD, MHA
7731 Old Canton Road, Suite B Madison, MS 39110
treatment provided for any illness, injury, or other health concern affecting me at any time I present at Mississippi
Center for Advanced Medicine (MCAM) for medical care. These services may include but are not limited to: laboratory procedures, in-office infusions, x-ray examinations, review of external pharmacy information and medical and/or surgical treatment or procedures. I understand that my insurance company and/or their agents may need information necessary to make determinations about payment/reimbursement. I hereby provide authorization to release to all insurance companies, their successors, assignees, other parties with whom they may have contracted, or others acting on their behalf, that are involved with payment for any hospital and/or clinic charges incurred by the patient, any information that they request and deem necessary for payment/reimbursement, and/or quality review. I further authorize the release of my health information to physicians or other health care practitioners on staff who are involved in my health care now and in the future, and to other health care providers, entities, or institutions for the purpose of my continued care and treatment, including referrals.
Federal laws require that MCAM submit every claim to an insurance company accurately and report the exact services performed and the exact reason for performing them. It is insurance fraud to change this
information in order to try to obtain payment on a claim from an insurance company.
I agree that in the event my insurance provider does not pay for some/all of the charges associated with and incurred for today’s visit, I will pay any remaining balance due and that balance will be my personal financial
responsibility. I understand that this only applies to MCAM. procedures and charges and that this excludes any and all charges incurred from third party entities as a result of laboratory testing, durable medical equipment, etc. I understand that this Medical Treatment and Financial Agreement is and will be valid for any and all services provided by MCAM effective from the date this Medical Treatment and Financial Agreement is signed by me and does not expire unless and until I inform our office directly that I no longer wish to have this Medical Treatment and Financial Agreement in effect.
I have been given the opportunity to read the office’s Notice of Privacy Practices and have had any questions addressed concerning that policy.
Patient's Refill Policy
refills. Repeated no shows or cancellations will result in a denial of refills. All prescriptions require a follow up appointment every 6 to 12 months.