PERSONAL INFORMATION

Last Name :

First Name :

M.I. :

Street Address :

Apt/Unit :

City :

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Zip Code :

Home Phone :

Cell Phone :

Work Phone :

EXT :

E-mail :

Date of Birth:

Birth Sex :

Sexual Orientation :

Gender Identity :

Race :

Social Security Number :

Ethnicity :

Marital Status :

GUARANTOR/ RESPONSIBLE PARTY INFORMATION

Last Name :

First Name :

M.I. :

Street Address :

Apt/Unit :

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Zip Code :

Home Phone :

Cell Phone :

Date of Birth:

EMERGENCY CONTACT

Last Name :

First Name :

Home Phone :

Cell Phone :

Relationship :

INSURANCE INFORMATION

Primary Insurance Name :

Policy Number :

Group Number :

Secondary Insurance Name :

Policy Number :

Group Number :

PHARMACY INFORMATION

Name :

Phone :

Fax :

Street Address :

City :

CONSENT FOR RELEASE OF MEDICAL INFORMATION

Rocky Mount Family Medical Center may release my medical information to the following:

Name :

Phone :

Relationship :

Name :

Phone :

Relationship :

Name :

Phone :

Relationship :

By Signing Below, I understand that I am granting permission to have any or all of my medical information, including financial information released to the persons listed above.

Date :

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY POLICY

I have been provided a copy of Rocky Mount Family Medical Center's Notice of privacy practices which informs me of uses, disclosures, and rights pertaining to my protected health information.

I acknowledge receipt of a copy of Rocky Mount Family Medical Center's Notice of Privacy Practices.

Print Name :

Date :

NOTICE OF PRIVACY PRACTICES

This notice describes how your Protected Health Information (PHI) may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your Protected Health Information is important to us.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give you this NOTICE about our privacy practices, our legal rights, as well as your legal rights concerning your health information. We must follow the privacy practices that are described within this Notice while it is in effect. This Notice takes effect 06/14/2011, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all protected health information that we maintain, including protected health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

We use and disclose protected health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your protected health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your protected health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your protected health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. We may also view your external prescription history via a RxHUB Service which will include history from other unaffiliated medical providers, insurance companies, and pharmacy benefit managers.

Your Authorization: In addition to our use of your protected health information for treatment, payment or healthcare operations, you may give us written authorization to use your protected health information and / or to disclose it to anyone person for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your protected health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your personal health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member or other person to the extent necessary to help with your healthcare or with payment for your healthcare. You will need to complete our Consent for Release of Medical Information form in order for us to release information to any other individuals.

Persons Involved in Care: We may use or disclose protected health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your protected health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose protected health information based on a determination using our professional judgment disclosing only protected health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up prescriptions, medical supplies, xrays, or other similar forms of personal health information.

Required by Law: We may use or disclose your protected health information when we are required to do so by law.

Marketing Health-Related Services: We will not release your protected health information to any outside agency for marketing communications without your written authorization. We may use your protected health information to occasionally notify you of precautions (such as medication that has been ordered discontinued by the FDA), event notices pertaining to healthcare events that we feel, based on past diagnoses you would be interested in, and annually recommended medical care (such as flu shot).

Abuse or Neglect: We may disclose your protected health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your protected health information to the extent necessary to avert a serious threat to your health and safety or the health and safety of others.

National Security: We may disclose to military authorities the protected health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials protected health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to a correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your protected health information to provide you with appointment reminders. We may use various forms of media to communicate with you. Some examples (may not be limited to) include voicemail messages, postcards, letters, text messages and / or electronic mail (e-mail).

PATIENT RIGHTS

Access: You have the right to look at or get copies of your protected health information, with limited exceptions. You must make a request in writing to obtain access to your protected health information. Written requests should be sent to the Medical Records Department at the address at the end of this Notice. Medical Records will have 60 days to comply with your request. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will provide a copy of up to four (4) visits at no cost to you; however, if there is a need greater than four (4) visits, then we will use a third party to retrieve, copy, and mail you your records. The third party we use to send you your records, charges a fee that is between you and the third party. You will be notified and required to pay the fee before your records will be mailed to you. You may also access your records through the patient portal provided to you by us from our website (www.rmfmc.com).

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your protected health information for purposes, other than treatment, payment, healthcare operations and certain other activities, since April 14, 2003. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your protected health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communications: You have the right to request that we communicate with you about your protected health information by alternative means or to alternative locations (your request must be in writing). Your request must specify the alternative means or location, and provide a satisfactory explanation of how payments will be handled under the alternative means or location you’ve requested.

Amendment: You have the right to request that we amend your protected health information (your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances.

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 about access to your protected health information or in response to a request you made to amend or restrict the use or disclosure of your protected health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us by using the contact Information listed at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. 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.

Contact Officer: Privacy Officer / HIPAA Compliance Officer
Telephone: 252-443-3133     Fax: 252-443-6726
Address: 804 English Road, Suite 100, Rocky Mount, North Carolina 27804