Patient Registration
Date
Patient Name
Social Security No.
Date of birth
Age
Sex
Male
Female
Email
Address
City
State
Zip
Home phone
Work phone
Mobile/Alt. phone
Marital status
Married
Single
Partner
Divorced
Widowed
Separated
Name of Employer (or School)
Grade
Student Status
Full-time
Part-time
Emergency contact name
Phone
Responsible Party
Responsible Party Name
Address
City
State
Zip
Home phone
Business phone
Social security no.
Relationship to patient
Place of employment
If other family members are seen in this office, please list
Insurance Information
Do you have healthcare insurance?
Yes
No
Primary insurance company
Policy no.
Group no.
Policy phone
Subscriber Name
Date of birth
Social security no.
Employer
Please upload a copy of your insurance card
Front
Back
Do you have secondary insurance?
Yes
No
Secondary insurance company
Policy no.
Group no.
Subscriber Name
Date of birth
Social security no.
Employer
Please upload a copy of your insurance card
Front
Back
Please upload a copy of your Photo ID
Assignment of Insurance Benefits / Release of Medical Information
I authorize Kansas City Psychiatric Group to release any medical information which may be requested to process claims for payment of medical services through an insurance carrier, prepaid medical plan or a government agency.
I request that payment be made to Kansas City Psychiatric Group for any bills for service rendered to me by my doctor.
I understand that I am financially responsible to my doctor for any balance not covered by this authorization. I understand that insurance filing is done as a courtesy for the patient and my doctor takes no responsibility for denial or delay of payment.
Responsible Party’s Signature
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature, and that I understand and agree to the above statements.
Date
Name of signee
Patient name
Informed Consent for Treatment
I give my consent for services for myself or my child/legal dependent with Kansas City Psychiatric Group and associated members of the professional staff to include evaluation, psychotherapy, medication management, testing (if indicated) and involvement in the treatment planning process. I may at any time decline specific recommendations.
*We reserve the right to discharge any patient from this practice at any time for failure to comply with treatment recommendations or office policy responsibilities. We will suggest referral options in this event.
Responsible Party’s Signature
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature, and that I understand and agree to the above statements.
Date
Name of signee
Patient name
Consent to Release Information to Primary Care Physician
Communication between behavioral health providers and your primary care physicians is important to help ensure that you receive comprehensive and quality health care. This information will not be released without your consent. This information may include diagnosis, treatment plan, progress, and medication if necessary.
I do
do not
authorize Kansas City Psychiatric Group to release information related to my evaluation and treatment to my primary care physician
Primary care physician
Phone
Address
City
State
Zip
Responsible Party’s Signature
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature, and that I understand and agree to the above statements.
Date
Name of signee
Patient name
Consent for E-Prescribing and Medication History
I understand that as a part of my electronic health record, Kansas City Psychiatric Group may transmit my prescriptions electronically as permitted, to the pharmacy that I designate as my primary pharmacy provider. Additionally, Kansas City Psychiatric Group will obtain the history of all my past prescriptions dating back two years from pharmacy benefit managers and I understand that those prescriptions will become a part of my electronic health record. By signing below I hereby give consent to the above actions.
Responsible Party’s Signature
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature, and that I understand and agree to the above statements.
Date
Name of signee
Patient name
Prior Authorization
Kansas City Psychiatric Group has adopted a policy, in order to comply with the HIPAA Privacy Regulation, requiring physicians and staff to obtain authorization from the patient to leave detailed messages for that patient. This policy is to protect the patient’s privacy. If there is not a signed consent on file, physicians and staff will only leave a name and telephone number on an answering machine, voicemail, or with a live person answering the phone.
I have been given a copy of the Notice of Privacy Practices prior to signing this consent. Kansas City Psychiatric Group reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Kansas City Psychiatric Group 8300 College Blvd., Suite 320, Overland Park, Kansas 66210. It is also available online at
www.kcpsych.com
.
By completing the consent below, you are allowing Kansas City Psychiatric Group physicians and its staff to leave a voice mail and/or send a text message via Curogram, our secure text messaging service. You may also specify what information may be left and with whom by noting the information below.
I give my consent to Kansas City Psychiatric Group physicians and staff to leave a message regarding scheduling, treatment, lab results or other information as necessary. (Check all that apply).
It is permissible to contact me at the telephone locations checked below:
Home phone number
Work phone number
Mobile phone number
It is permissible to leave voice messages at the telephone locations checked below:
Home phone number
Work phone number
Mobile phone number
My preference for automated appointment reminders is (check one):
Voice call to Home Telephone Number
Voice call to Mobile Telephone Number
Text Reminder to Mobile Telephone Number
Email reminder to email above
Patient or Legal Guardian’s Signature
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature, and that I understand and agree to the above statements.
Date
Name of signee
Patient name
Adult Questionnaire
Date
Patient Name
Date of birth
Age
Sex
Male
Female
Height
Weight
KCPG Requested Provider
Please Select
David Brown, MD
Rimi Grewal, MD
Garrett Lambert, MD
Rubin Moore, Jr., MD
John Netherton, DO
Stephen Samuelson, MD
Jordan Stanton, DO
Jacque Dennihan, MS, LCMFT
Mary Helen Dennihan, MS, LCMFT
Mike Hanson, LSCSW
No Preference
Referred by
Presenting Problems
List your difficulties or other needs we may assist you with.
Please select any of the following problems which pertain to you:
Aggression
Alcohol use
Anxiety
Appetite changes
Binge eating
Confusion
Daytime napping
Depression
Dizziness
Drug use
Eating problems
Excessive sleep
Food restriction
Guilt
Headaches
Hearing voices
Homicidal thoughts
Hopelessness
Hypersexuality
Inability to sleep
Inattention
Involuntary movement
Irritability
Low interest in activities
Learning problems
Loneliness
Mood swings
Nervousness
Nightmares
Obsessive thoughts
Panic attacks
Paranoia
Poor memory
Purging
Racing thoughts
Restlessness
Seeing visions
Self injury
Sexual problems
Sleep changes
Stomach Aches
Stress
Suicidal thoughts
Tiredness
Unhappiness
Vivid dreams
Weight gain
Weight loss
Psychiatric History
Have you ever received psychological help or counseling of any kind before?
Yes
No
Are you currently being treated for a psychiatric illness?
Yes
No
Please explain
Please list all psychiatric or therapeutic treatment on either an outpatient or inpatient basis.
Date
Hospital or Clinician
Reason
Add another?
Add another?
Add another?
Add another?
Add another?
Add another?
Add another?
Add another?
Add another?
List any suicide attempts
Describe any traumatic events
Medical and Surgical History
Please list all surgical or medical treatment given you on either an outpatient or inpatient basis.
Date
Hospital/Doctor
Reason
Add another?
Add another?
Add another?
Add another?
Add another?
Add another?
Add another?
Add another?
Add another?
Are you currently being treated for a medical illness?
Yes
No
Please explain
Do you have/have you had any of the following
Overweight
Blood sugar problems
High blood pressure
Pregnancies -
number
High cholesterol
Live births -
number
Thyroid problems
List ALL MEDICATIONS you are currently taking
List all psychiatric medications you have taken in the PAST (e.g. antidepressant, anxiety medication, sleeping pills, etc.)
Are you allergic to any medication or have other allergies?
Drug and Alcohol History
List below all forms of alcohol, drugs and prescription drugs which you have ever used or abused.
Alcohol
Amount
First Use
Last Use
Marijuana
Amount
First Use
Last Use
Cocaine
Amount
First Use
Last Use
Methamphetamine
Amount
First Use
Last Use
LSD/Opiates/Heroin/IV Drugs
Amount
First Use
Last Use
Other
Describe
Amount
First Use
Last Use
Caffeine (coffee, soda, etc.)
Amount
First Use
Last Use
Nicotine (cigarettes, etc.)
Amount
First Use
Last Use
Have you ever received treatment for drug and/or alcohol abuse problems?
Yes
No
Please describe
Family History
Do you have any relatives with known or suspected psychiatric or emotional difficulties (i.e. depression, anxiety, alcohol or drug abuse, schizophrenia, learning disabilities, hyperactivity, etc?)
Mother
Please describe
Father
Please describe
Siblings
Please describe
Children
Please describe
Other
Please describe
Has anyone related to you attempted suicide or died by suicide?
Yes
No
Please describe
Marital History
Marital status
Married
Single
Partner
Divorced
Widowed
Separated
Dates of marriage
From
To
Number of years
Previous marriage
From
To
Number of years
Previous marriage
From
To
Number of years
Number of children
Biological
Stepchildren
Living Situation
Please list people living in the home
Name
Relationship
Age
Sex
Add another?
Add another?
Add another?
Add another?
Add another?
Are there firearms in the home?
Yes
No
How are they secured?
Educational History
High School
Years completed
Did you graduate?
Yes
No
Trade/Technical
Years completed
Did you graduate?
Yes
No
Jr. College
Years completed
Did you graduate?
Yes
No
College
Years completed
Did you graduate?
Yes
No
If you dropped out before completing education, please explain
How well did you do with your studies? Please explain
Employment History
Please list all employment from over the last five (5) years
Company
Position
From
To
Reason for Leaving
Add another?
Add another?
Add another?
Add another?
Military History
Branch of service
From
To
Rank
Type of discharge
Legal History
Please describe
Patient Health Questionnaire (PHQ-9)
1. Over the
last 2 weeks
how often have you been bothered by any of the following problems?
Please Select
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
a. Little interest or pleasure in doing things.
Please Select
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
b. Feeling down, depressed or hopeless.
Please Select
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
c. Trouble falling or staying asleep, or sleeping too much.
Please Select
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
d. Feeling tired or having little energy.
Please Select
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
e. Poor appetite or overeating.
Please Select
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
f. Feeling bad about yourself or that you are a failure or have let yourself or your family down.
Please Select
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
g. Trouble concentrating on things, such as reading the newspaper or watching television.
Please Select
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
h. Moving or speaking slowly enough that other people take notice. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual.
Please Select
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
i. Thoughts that you would be better off dead or of hurting yourself in some way.
2. If you checked any problems so far, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Informed Consent for Telehealth
This Informed Consent for Telehealth contains important information focusing on providing healthcare services using the phone or the Internet. Please read this carefully, and let me know if you have any questions. When you sign this document, it will represent an agreement between us.
I understand that my psychiatrist recommends engaging in telehealth services with me to provide treatment.
I understand that telehealth is currently the only option for care out of necessity and an abundance of caution due to the Coronavirus pandemic while we remain in a Public Health Emergency (PHE) status. Once the PHE is lifted, telehealth will remain an option as long as I and my physician both agree that it is appropriate for my circumstances.
I understand that telehealth treatment has potential benefits including, but not limited to, easier access to care.
I understand that telehealth has been found to be effective in treating a wide range of disorders, and there are potential benefits including, but not limited to easier access to care. I understand, however, there is no guarantee that all treatment of all patients will be effective.
I understand and agree that it is my obligation to be located in either Kansas or Missouri for each treatment session.
I understand that it is my obligation to notify my physician of any other persons in the location, either on or off camera and who can hear or see the session. I understand that I am responsible to ensure privacy at my location. I will notify my physician at the outset of each session and am aware that confidential information may be discussed.
I understand that it is my obligation to ensure that any virtual assistant artificial intelligence devices, including but not limited to Alexa or Echo, will be disabled or will not be in the location where information can be heard.
I agree that I will not record either through audio or video any of the session, unless I notify my physician and this is agreed upon.
I understand there are potential risks to using telehealth technology, including but not limited to, interruptions, unauthorized access and technical difficulties. I understand some of these technological challenges include issues with software, hardware, and internet connection which may result in interruption.
I understand that my physician is not responsible for any technological problems of which my physician has no control over. I further understand that my physician does not guarantee that technology will be available or work as expected.
I understand that I am responsible for information security on my device, including but not limited to, computer, tablet or phone, and in my own location.
I understand that my physician or I (or, if applicable, my guardian or conservator), can discontinue the telehealth consult/visit if it is determined by either me or my physician that the videoconferencing connections or protections are not adequate for the situation.
I have had a conversation with my physician, during which time I have had the opportunity to ask questions concerning services via telehealth. My questions have been answered, and the risks, benefits, and any practical alternatives have been discussed with me.
Doxy.me is the technology service we will use to conduct telehealth videoconferencing appointments. My physician has discussed the use of this platform. Prior to each session, I will receive an email link to enter the virtual waiting room until the session begins. There are no passwords or log in required.
By signing this document, I acknowledge:
Doxy.me is NOT an emergency service. Doxy.me facilitates videoconferencing and this technology platform is not, itself, a source of healthcare, medical advice or care. In the event of an emergency, I will use a phone to call 9-1-1 and/or other appropriate emergency contact.
I recognize my physician may need to notify emergency personnel in the event he/she feels there is a safety concern, including but not limited to, a risk to self/others or my physician is concerned that immediate medical attention is needed.
I understand that the same fee rates apply for telehealth as apply for in-person treatment. It is my obligation to contact my insurer before engaging in telehealth to determine if there are applicable co-pays or fees which I am responsible for. Insurance or other managed care providers may not cover telehealth sessions. I understand that if my insurance, HMO, third-party payor, or other managed care provider do not cover the telehealth sessions, I will be solely responsible for the entire fee of the session.
I understand that telehealth communication is for scheduled visits ONLY. For communication between sessions, the office should be contacted at (913) 338-0400. This includes things like setting and changing appointments, billing matters, medication questions and other clinical questions and concerns.
To maintain confidentiality, I will not share my telehealth appointment link or information with anyone not authorized to attend the session.
I understand that either I or my physician can discontinue the telehealth services if those services do not appear to benefit me therapeutically or for other reasons which will be explained to me. I understand there may be no other treatment alternative available.
KCPG telehealth link:
https://kcpsych.doxy.me/kcpglobbymain
I have read and understand the information provided above regarding telehealth, have discussed it with my physician, and I hereby give informed consent to the use of telehealth.
Patient or Guardian/Conservator Signature
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature, and that I understand and agree to the above statements.
Date
Name of signee
Patient name (if child)
Office Policies
Please read the following information carefully
Our office will do whatever we can to assist you. If you have any questions or problems, please do not hesitate to contact our billing office.
All patients must complete the patient information form and sign this policy agreement in order to be seen in this office.
I have read and agree to the below office policies.
Signature
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature, and that I understand and agree to the above statements.
Date
Dear Patients and Families,
We thank you for choosing KCPG and look forward to working with you. We strive to provide the very best care and in order to do so we would like to take this opportunity to acquaint you with our office policies. Please take a few moments to read over the following information.
In addition, we suggest you review your health insurance policy and familiarize yourself with the coverage and limitations that it provides.
APPOINTMENTS
We ask that you try to schedule your appointments as soon as possible - hopefully after each office visit - as routine follow-up time slots are typically booked for several weeks into the future at any given point in time. If you are unable to keep your appointment, please notify our office one working day
(24 hours)
in advance, to avoid being billed for the time.
A missed appointment will be billed at a rate determined by your physician and charged to your account. As insurance does not pay for missed appointments, the patient/guarantor is responsible. Please note that two consecutive missed appointments may result in being discharged from care.
We will make an attempt to contact you to confirm each appointment two working days ahead of time. This call is a
courtesy
, and our failure to reach you will not relieve you of your responsibility for any missed appointment charges.
PRESCRIPTIONS
If you are on medication, please request any needed renewal prescriptions at the time of your appointment. In general, you will be provided enough refills to last until your next expected appointment. If you do require refills between appointments,
please contact us at (913) 338-0400, option 4 during regular phone hours 9AM to 4PM Monday through Thursday and 9AM to Noon on Friday. Please notify our office of a need for a prescription three business days in advance, as we do not provide “emergency fills”. Failure to make follow-up appointments as directed by the doctor, or missing a scheduled appointment, may result in a prescription fee. We do not accept fill requests from the pharmacy. If a refill is needed the patient must contact our office directly.
LETTERS AND FORM COMPLETION
We require a minimum of 48 hours for all letters and form completion. Any information that you would like forwarded to another provider, school, attorney, employer, etc. requires a signed release of information. In some cases, we may require you to schedule an appointment for the completion of these forms. Please contact our office to inquire whether a scheduled appointment will be necessary.
There may be a fee associated
.
Financial Policy
IF YOU DO NOT HAVE INSURANCE
If you do not have insurance there will be a one-time up front deposit when scheduling your initial appointment. This payment will go towards your first appointment fee. If you cancel your appointment with at least one working day
(24 hours)
notice your payment will be reimbursed in full. If you cancel with less than 24 hours notice or no show your payment is forfeited as a missed appointment fee. We ask that all self pay patients pay in full at the time of service and in turn will be given a discount. If you cannot pay in full we must receive payment before scheduling your next appointment.
IF YOU HAVE INSURANCE
In order to better serve your needs, our office accepts several insurance plans. However, every plan is different. It is up to the insured to know the exact coverage and limitations of their own insurance plan. In order for us to file insurance claims on your behalf, you must present proper proof of insurance at the time of your appointment to our office.
NO INSURANCE WILL BE FILED WITHOUT A COPY OF THE INSURANCE CARD.
Fees due at the time of service include: co-pays, deductibles, non-covered services, or services to patients that are not covered by insurance. For your convenience we accept, cash, check, MasterCard, Visa, American Express, and Discover. If your check is returned from your financial institution you will be subject to a $30 service charge and we will no longer be able to accept checks on your behalf.
IF YOU HAVE AN OUT OF NETWORK (OON) INSURANCE PLAN
If your health plan is out of network with our practice we have structured our fees to be competitive in the local market to allow you to see our providers at a reasonable rate. It is our goal that we are accessible to you, and we offer the following payment options for out of network plans:
Some plans do have out of network benefits. We will be happy to bill your insurance as a courtesy; however, payment will be due from you at the time of service. Your insurance carrier will reimburse you directly for any out of network coverage you may have. Additionally, these charges will be applied toward any deductible that you may have to meet.
Alternately, you may choose to be seen as a self-pay patient. We will not be able to file your insurance for you with this option; however, we can offer you a
prompt pay discount when you pay in full on the date of service
. With this option you are welcome to file your insurance claim on your own for possible reimbursement.
FINANCIAL RESPONSIBILITY
The person who brings a child for care is ultimately responsible for their bill. The physicians will not get involved in a court decision or child support disputes.
YOU WILL RECEIVE A MONTHLY STATEMENT OF YOUR ACCOUNT AS LONG AS YOU HAVE A BALANCE.
In general, insurance companies should pay within thirty to sixty days after receipt of a claim. If your insurance has not paid by sixty days after your visit, please check with your company as to the status of your claim.
Your insurance benefits are a contract between you and your insurance company. We cannot accept responsibility for collecting your insurance or for negotiating a settlement on a disputed claim, but we will assist you whenever possible.
If you are a member of a health plan for which we are participating providers, we will honor any restrictions on charges or fees, and these will be adjusted accordingly.
*** WE RESERVE THE RIGHT TO SEND AN ACCOUNT TO COLLECTIONS IF NOT PAID IN FULL. IF KCPG REFERS YOUR ACCOUNT OVER TO A COLLECTION AGENCY, YOU WILL BE RESPONSIBLE FOR YOUR BALANCE PLUS THE COLLECTION AGENCY FEES ***
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Kansas City Psychiatric Group is committed to protecting your personal health information. If at any time you have any questions or concerns about how your confidential information is being used you are encouraged to notify the practice staff so that appropriate personnel can quickly address and resolve these concerns.
Effective Date: April 13, 2003
This Notice was revised on July 30, 2018.
IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT OUR PRIVACY OFFICER:
Privacy Officer:
Mailing Address:
Telephone:
Fax:
Temperance McFarland
8300 College Blvd, Suite 320, Overland Park, KS 66210
(913) 338-0400
(913) 338-0428
About This Notice
We are required by law to maintain the privacy of Protected Health Information and to give you this Notice explaining our privacy practices with regard to that information. You have certain rights – and we have certain legal obligations – regarding the privacy of your Protected Health Information, and this Notice also explains your rights and our obligations. We are required to abide by the terms of the current version of this Notice.
What is Protected Health Information?
“Protected Health Information” is information that individually identifies you and that we create or get from you or from another health care provider, health plan, your employer, or a health care clearinghouse and that relates to (1) your past, present, or future physical or mental health or conditions, (2) the provision of health care to you, or (3) the past, present, or future payment for your health care.
How We May Use and Disclose Your Protected Health Information
We may use and disclose your Protected Health Information in the following circumstances:
For Treatment
. We may use or disclose your Protected Health Information to give you medical treatment or services and to manage and coordinate your medical care. For example, your Protected Health Information may be provided to a physician or other health care provider (e.g., a specialist or laboratory) to whom you have been referred to ensure that the physician or other health care provider has the necessary information to diagnose or treat you or provide you with a service.
For Payment
. We may use and disclose your Protected Health Information so that we can bill for the treatment and services you receive from us and can collect payment from you, a health plan, or a third party. This use and disclosure may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, we may need to give your health plan information about your treatment in order for your health plan to agree to pay for that treatment.
For Health Care Operations
. We may use and disclose Protected Health Information for our healthcare operations. For example, we may use your Protected Health Information to internally review the quality of the treatment and services you receive and to evaluate the performance of our team members in caring for you. We also may disclose information to physicians, nurses, medical technicians, medical students, and other authorized personnel for educational and learning purposes.
Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services
. We may use and disclose Protected Health Information to contact you to remind you that you have an appointment for medical care, or to contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you.
Minors
. We may disclose the Protected Health Information of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law.
Research
. KCPG does not participate in any research activities.
As Required by Law
. We will disclose Protected Health Information about you when required to do so by international, federal, state, or local law.
To Avert a Serious Threat to Health or Safety
. We may use and disclose Protected Health Information when necessary to prevent a serious threat to your health or safety or to the health or safety of others, but we will only disclose the information to someone who may be able to help prevent the threat.
Business Associates
. We may disclose Protected Health Information to our business associates who perform functions on our behalf or provide us with services if the Protected Health Information is necessary for those functions or services. For example, we may use another company to do our billing, or to provide transcription or consulting services for us. All of our business associates are obligated, under contract with us, to protect the privacy and ensure the security of your Protected Health Information.
Organ and Tissue Donation
. If you are an organ or tissue donor, we may use or disclose your Protected Health Information to organizations that handle organ procurement or transplantation – such as an organ donation bank – as necessary to facilitate organ or tissue donation and transplantation.
Military and Veterans
. If you are a member of the armed forces, we may disclose Protected Health Information as required by military command authorities. We also may disclose Protected Health Information to the appropriate foreign military authority if you are a member of a foreign military.
Workers’ Compensation
. We may use or disclose Protected Health Information for workers’ compensation or similar programs that provide benefits for work-related injuries or illness.
Public Health Risks
. We may disclose Protected Health Information for public health activities. This includes disclosures to: (1) a person subject to the jurisdiction of the Food and Drug Administration (“FDA”) for purposes related to the quality, safety or effectiveness of an FDA-regulated product or activity; (2) prevent or control disease, injury or disability; (3) report births and deaths; (4) report child abuse or neglect; (5) report reactions to medications or problems with products; (6) notify people of recalls of products they may be using; and (7) a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
Abuse, Neglect, or Domestic Violence
. We may disclose Protected Health Information to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence and the patient agrees or we are required or authorized by law to make that disclosure.
Health Oversight Activities
. We may disclose Protected Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure, and similar activities that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Data Breach Notification Purposes
. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.
Lawsuits and Disputes
. If you are involved in a lawsuit or a dispute, we may disclose Protected Health Information in response to a court or administrative order. We also may disclose Protected Health Information in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get an order protecting the information requested. We may also use or disclose your Protected Health Information to defend ourselves in the event of a lawsuit.
Law Enforcement
. We may disclose Protected Health Information, so long as applicable legal requirements are met, for law enforcement purposes.
Military Activity and National Security
. If you are involved with military, national security or intelligence activities or if you are in law enforcement custody, we may disclose your Protected Health Information to authorized officials so they may carry out their legal duties under the law.
Coroners, Medical Examiners, and Funeral Directors
. We may disclose Protected Health Information to a coroner, medical examiner, or funeral director so that they can carry out their duties.
Inmates
. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose Protected Health Information to the correctional institution or law enforcement official if the disclosure is necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.
Uses and Disclosures That Require Us to Give You an Opportunity to Object and Opt Out
Individuals Involved in Your Care or Payment for Your Care
. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.
Disaster Relief
. We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practicably can do so.
Fundraising Activities
. KCPG does not participate in any fundraising activities.
Your Written Authorization is Required for Other Uses and Disclosures
The following uses and disclosures of your Protected Health Information will be made only with your written authorization:
Most uses and disclosures of psychotherapy notes;
Uses and disclosures of Protected Health Information for marketing purposes; and
Disclosures that constitute a sale of your Protected Health Information.
Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information under the authorization, but disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.
Your Rights Regarding Your Protected Health Information
You have the following rights, subject to certain limitations, regarding your Protected Health Information:
Right to Inspect and Copy
. You have the right to inspect and copy Protected Health Information that may be used to make decisions about your care or payment for your care. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional chosen by KCPG who was not directly involved in the denial of your request, and we will comply with the outcome of the review.
Right to a Summary or Explanation
. We can also provide you with a summary of your Protected Health Information, rather than the entire record, or we can provide you with an explanation of the Protected Health Information which has been provided to you, so long as you agrees to this alternative form and pay the associated fees.
Right to an Electronic Copy of Electronic Medical Records
. If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.
Right to Get Notice of a Breach
. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.
Right to Request Amendments
. If you feel that the Protected Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for us. A request for amendment must be made in writing to the Privacy Officer at the address provided at the beginning of this Notice and it must tell us the reason for your request. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
Right to an Accounting of Disclosures
. You have the right to ask for an “accounting of disclosures,” which is a list of the disclosures we made of your Protected Health Information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice. It excludes disclosures we may have made to you, for a resident directory, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to certain exceptions, restrictions and limitations. Additionally, limitations are different for electronic health records. The first accounting of disclosures you request within any 12-month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting. We will tell what the costs are, and you may choose to withdraw or modify your request before the costs are incurred.
Right to Request Restrictions
. You have the right to request a restriction or limitation on the Protected Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Protected Health Information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. To request a restriction on who may have access to your Protected Health Information, you must submit a written request to the Privacy Officer. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to your request, unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we do agree to the requested restriction, we may not use or disclose your Protected Health Information in violation of that restriction unless it is needed to provide emergency treatment.
Out-of-Pocket-Payments
. If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
Right to Request Confidential Communications
. You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a specific address or call you only at your work number. You must make any such request in writing and you must specify how or where we are to contact you. We will accommodate all reasonable requests. We will not ask you the reason for your request.
Right to a Paper Copy of This Notice
. You have the right to a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time.
How to Exercise Your Rights
To exercise your rights described in this Notice, send your request, in writing, to our Privacy Officer at the address listed at the beginning of this Notice. We may ask you to fill out a form that we will supply. To exercise your right to inspect and copy your Protected Health Information, you may also contact your physician directly.
Changes To This Notice
We reserve the right to change this Notice. We reserve the right to make the changed Notice effective for Protected Health Information we already have as well as for any Protected Health Information we create or receive in the future. A copy of our current Notice is posted in our office.
Complaints
You may file a complaint with us or with the Secretary of the United States Department of Health and Human Services if you believe your privacy rights have been violated.
To file a complaint with us, contact our Privacy Officer at the address listed at the beginning of this Notice. All complaints must be made in writing and should be submitted within 180 days of when you knew or should have known of the suspected violation. There will be no retaliation against you for filing a complaint.
To file a complaint with the Secretary, mail it to: Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. Call (202) 619-0257 (or toll free (877) 696-6775) or go to the website of the Office for Civil Rights, www.hhs.gov/ocr/hipaa/, for more information. There will be no retaliation against you for filing a complaint.