Adult Patient Health History
Please complete both sides of form
This questionnaire is used to collect information about your current health history. In addition to providing your health care team with
important clinical information, this questionnaire also helps us meet special requirements established by Medicare and other health
insurers.
Patient Information:
Name: __________________________________ Date of Birth: ____________________ Birth place: _________________________
Religion: _______________ Gender: □Male □Female Race: □White □Black □Hispanic □Asian □Other, specify ________________
Marital Status: □Single
□Married
□Divorced
What is your primary language? ________________________________
Primary Care/Family Physician’s Name: ______________________________________
City: _____________________________
Allergies:
Have you had hives, skin rash, breathing problems or other allergic reactions to medications? □Yes □No If yes, please list below:
Name of medicine
Describe allergic reaction
____________________________
___________________________________________________________________________
Are there medications, other than those you are allergic to, you would prefer not to take due to prior unpleasant side effects?
□Yes □No
If yes, please specify: _______________________________________________________________________________
Have you had allergic reaction to: Iodine or x-ray contrast dye? □Yes □No Latex or rubber (gloves, condoms, balloons)? □Yes □No
Shell fish? □Yes □No
Bee or wasp stings? □Yes □No
List any food allergies: □None
Adhesive tape? □Yes □No Other allergies (specify): _________________
________________________________________________________________________________
Height: ____ Weight: ____ Date of last Flu shot: ____ Recent weight change? □No □Yes Gain of ____ lbs. Loss of ___ lbs.
Past Medical history:
Check if you have or have had any of the following:
□Allergies
□Cerebrovascular accident
□Anemia
□COPD
□Angina
□Coronary artery disease
□Anxiety
□Chron’s disease
□Arthritis
□Depression
□Asthma
□Diabetes
□Atrial fibrillation
□Gallbladder disease
□Benign prostatic hypertrophy
□GERD
□Blood clots
□Hepatitis C
□Cancer
□Hyperlipidemia
(type:__________________________)
Past surgical history:
Please check all that applies:
Year
□Angioplasty
__________
□Colectomy
□Hypertension
□Irritable bowel disease
□Liver disease
□Migraine headaches
□Myocardial infection
□Osteoarthritis
□Osteoporosis
□Peptic ulcer disease
□Renal disease
□Seizure disorder
□Thyroid disease □Other (specify):____________
Year
__________
□Pacemaker
Year
__________
□Angio w/ stent
__________
□Colostomy
__________
□Prostate biopsy
__________
□Appendectomy
__________
□Gastric bypass
__________
□Small bowel resection
__________
□Arthroscopy
__________
□Hernia repair
__________
□Thyroidectomy
__________
□Back surgery
__________
□Hip replacement
__________
□Tonsillectomy
__________
□CABG
__________
□Knee replacement
__________
□TURP
__________
□Carpal tunnel
__________
□LASIK
__________
□Vasectomy
__________
□Cataract
extraction
□Cholecystectomy
__________
□Liver biopsy
__________
□Other (specify):
__________________________________
__________
□ORIF
__________
Hospitalizations:
Please list past major hospitalizations:
Year
Place
Illness/Injury
Doctor
_____________
_______________
__________________________
______________________________
_____________
_______________
__________________________
______________________________
Patient’s Social History and Habits:
Occupation: __________________
Currently employed? □Yes □No
If employed: □Full time □Part-time
Are you a student? □Yes
□No
Education (highest level completed) ____________
Exercise:
Are you in the military? □Yes
□No
Coffee:
Do you exercise?
□Yes
□No
Do you drink coffee?
How often do you exercise?___________________
□Yes
□No
How many cups of coffee do you drink in a day? __________
What type of exercise (walking, running, swimming)? __________________________________________________________________
Tobacco:
Do you currently use tobacco? □Yes
□No
Alcohol:
Do you drink alcohol?
□Yes
□No
How many years have you used tobacco regularly? ___________
What type of alcohol? _______________
What form of tobacco do you currently use
cigarettes, pipe, cigar, chew)? __________
How much do you drink in a usual week? __________
When did you last drink? _____________
How much tobacco do you use each day? ___________
When did you quit drinking? _____________
Ever tried to quit?
□Yes
□No
Have you used tobacco in the past?
□Yes
□No
Family History:
Please check if any family members have had any of the following and who in the family had it. (Example: Allergies: Mother)
□Allergies__________________
□Cancer _________________
□High blood pressure __________________
□Alcoholism ________________
□Diabetes ________________
□Kidney disease ______________________
□Asthma __________________
□Epilepsy ________________
□Mental Health disorder _______________
□Bleeding tendency __________
□Heart disease ____________
□Tuberculosis ________________________
□Blindness _________________
□Hearing loss _____________
□Stroke/CVA _________________________
□Neurological disorder _______
□Other (specify) ______________________________________
Please list the following information about your family:
Year of birth
Major Illness (if applicable, cause of death)
Living/Deceased
Father
_________
_____________________________________________________
Mother
_________
_____________________________________________________
Siblings
Gender
If deceased, what age?
________________
________________
_________
□M
□F
_____________________________________________________
________________
_________
□M
□F
_____________________________________________________
________________
Children
Gender
_________
□M
□F
_____________________________________________________
________________
_________
□M
□F
_____________________________________________________
________________
Please list below all the medications you are currently taking and who prescribed it:
Medications
Prescribing Doctor
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Patient Signature ____________________________________
Date: ______________________________________________
Promise Healthcare Application for Sliding Fee Scale Discount If you need assistance completing any part of this application, please talk with a Promise Healthcare staff member. Only one form is necessary per household Is your medical coverage through Medicaid or a Medicaid managed care plan? £ Yes £ No If YES, skip this form and verify income on our Medicaid form. Applicant Name: _____________________ Birthdate: ________ Social Security Number: _________ Address: ___________________________________ Phone Number: _________________________ City: __________ State: ____ Zip: ________ Alternate Phone Number: ______________________ Email Address: __________________________________________________ Do you or does someone in your family have medical insurance? £ Yes £ No Do you or does someone in your family have dental insurance? £ Yes £ No If yes, please complete below. Add additional sheets as necessary. Medical Insurance Company Name: ________________________________________________________ Policy #: __________________ Group #: __________________ Subscriber #: __________________ Company Address: ___________________________ City: __________ State: ____ Zip: ________ Dental Insurance Company Name: _________________________________________________________ Policy #: __________________ Group #: __________________ Subscriber #: __________________ Company Address: ___________________________ City: __________ State: ____ Zip: ________ Are you a U.S. veteran? £ Yes £ No Within the last 24 months, have you worked or are you the dependent of someone who has worked in agriculture, either on a farm or in an agricultural-­‐based industry? £ Yes £ No If yes, which applies? £ Migrant (establishes temporary residence in area) £ Year-­‐Round Employment (permanent residence in area) £ Seasonal Permanent Resident (permanent resident in area) Type of Housing (check one) £ Rent or own home £ Homeless Shelter £ Doubled Up (live with another person or family unit) £ Transitional (live place to place) £ Street £ Other List all dependents (if more than 6 dependents, please list on separate page) Do They Have: Relationship to Applicant Medicaid Other Insurance Name and Social Security Number Date of Birth Page 1 of 2 Income Summary Table Sources Total Household Income Accepted Documentation Wages Interest/Dividend Income Self-­‐Employment, Rental Income Public Assistance, Social Security/Disability Last federal income tax return or last two paycheck stubs prior to the signature date on this application. Bank, credit union, savings statement or 1099. Ledger of income and expenses for the current year. Award letter(s) listing amount received in the current year. If you receive more than one, please add them together. Unemployment Compensation Workers Compensation Child Support, Alimony Unemployment compensation benefit award letter for the current year. Worker’s compensation benefit award letter for the current year. Retirement Pension Assistance from Family/Friends Other (Specify) Total Divorce decree stating child support or alimony received. Letter supplied by system administrator with monthly benefit amount for the current year. A notarized statement from family or friends explaining any financial help that they give you. Number of people supported by household income: ____________________ If you have any additional documents that may help Promise Healthcare make a determination regarding your application, please include them with this application. Patients who qualify for certain levels of sliding fee discounts are expected to also apply for other programs if requested to do so including Medicaid, other public and/or private health insurance and/or discount programs available for which you may qualify, including prescription drug assistance from pharmaceutical companies. Although a patient’s inability to pay for services will not prohibit services being provided, a patient who refuses to pay even though able to pay will be subject to collection activities. Patients are expected to be in compliance with Health Resources and Services Administration/Bureaus of Primary Health Care policies and regulations in order to receive medical services. I understand that all of the information given may be confirmed by Promise Healthcare. I also understand that providing false information is considered fraud and will result in a denial of the Sliding Fee Scale Program application and that I will owe the charges for the services provided. I understand that if I am approved, the discount is good for one year from the date of the application and that I will need to complete another application at that point in order for the discount to continue. I also understand that if I am approved for the discount, I am obligated to inform Promise Healthcare if my financial situations improve, so that Promise Healthcare can re-­‐evaluate my eligibility for the discount. Applicant Signature (required): __________________________________________ Date: __________ Promise Healthcare Internal Use Only: Total Income: _______________ Number in Household: _______________ Staff Signature: _______________________________________________________ Date: __________ Page 2 of 2 Income Form 1 Income Certification Medicaid Only one form is necessary per household Applicant Name: _____________________ Birthdate: ________ Social Security Number: _________ Address: ___________________________________ Phone Number: _________________________ City: __________ State: ____ Zip: ________ Alternate Phone Number: ______________________ Email Address: __________________________________________________ Do you or does someone in your family have medical insurance? £ Yes £ No Do you or does someone in your family have dental insurance? £ Yes £ No Medical Insurance Company Name: ________________________________________________________ Policy #: __________________ Group #: __________________ Subscriber #: __________________ Company Address: ___________________________ City: __________ State: ____ Zip: ________ Dental Insurance Company Name: _________________________________________________________ Policy #: __________________ Group #: __________________ Subscriber #: __________________ Company Address: ___________________________ City: __________ State: ____ Zip: ________ Are you a U.S. veteran? £ Yes £ No Within the last 24 months, have worked you or are you the dependent of someone who has worked in agriculture, either on a farm or in an agricultural-­‐based industry? £ Yes £ No If yes, which applies? £ Migrant (establishes temporary residence in area) £ Year-­‐Round Employment (permanent residence in area) £ Seasonal Permanent Resident (permanent resident in area) Type of Housing (check one) £ Rent or own home £ Homeless Shelter £ Doubled Up (live with another person or family unit) £ Transitional (live place to place) £ Street £ Other Name Date of Birth Relationship to Applicant Recipient Number I certify I am Medicaid-­‐eligible and decline the sliding fee scale application. I understand that I will be financially responsible for any Medicaid copays/spend-­‐downs or services provided if I am not Medicaid-­‐
eligible when I receive services at Promise Healthcare. Number of people supported by household income: ______________ Household Income: _________ Signature: ________________________________________________ Date: ____________________ Promise Healthcare Internal Use Only: Total Income _____________ Patient Name: _____________________________ Number in Household: _______________ Staff Signature: _______________________________________________________ Date: __________ Income Form 2 Welcome!
What to expect on your first visit.
Promise Healthcare is dedicated in providing you with high-quality medical, mental health, and
dental care in a friendly, caring, and efficient environment. The trust and confidence you have
placed in us is greatly appreciated.
In an effort to make your first visit pleasant and efficient, we have several patient information
forms to be completed asking about your medical history, current medical problems,
medications, allergies, family history and social history. We recommend that you bring all your
medications to your appointment – including current pills, inhalers, and insulin. We might not
be able to prescribe your medications at your first visit, but we will do our best. If you have a
complicated medical situation, you may be scheduled for a follow-up appointment.
Please understand that we do not prescribe narcotics or other controlled medications
(including anxiety and ADD/ADHD medications) at your first visit. There are several reasons:
-
-
We may need to verify your prescription from your pharmacy
We may need to verify your prescriptions through monitoring agencies
We may need to contact you previous provider
We will need to do drug screening
We will need time to go over an Informed Consent Agreement – an agreement that
you and your provider sign allowing your provider to begin prescribing your
medications
We may ask you to set-up an appointment with other specialists as part of your
Informed Consent Agreement.
You and your provider will develop a shared plan of care. Your provider may recommend that
you see our health educators and/or mental health providers to optimize your care. When
necessary, your provider will refer you to an outside specialist.
I have read this form and understand my first visit expectations.
Patient Name: ________________________________________
DOB______________
Patient Signature: _____________________________________
Date: _____________
819 Bloomington Road • Champaign, IL 61820
(217) 356-1558 • www.promisehealth.org
Notice of Disclosure Under the Illinois Mental Health and Developmental Disabilities Confidentiality Act (Act), Promise Healthcare may disclose your patient records without your consent under certain circumstances defined under the Act. For example, Promise Healthcare may disclose your patient records – including records that fall within the Act – to Community Elements. For your convenience, below are some portions of the Act that may apply to permit Promise Healthcare to disclose your patient records or communications under certain circumstances without your consent: “In the course of providing services and after the conclusion of the provision of services, including for the purposes of treatment and care coordination, a therapist, integrated health system, or member of an interdisciplinary team may use, disclose, or re-­‐disclose a record or communications without consent to: (1) the therapist's supervisor, a consulting therapist, members of a staff team participating in the provision of services, a record custodian, a business associate, an integrated health system, a member of an interdisciplinary team, or a person acting under the supervision and control of the therapist; . . . Information may be disclosed under this Section only to the extent that knowledge of the record or communications is essential to the purpose for which disclosure is made and only after the recipient is informed that such disclosure may be made. A person to whom disclosure is made under this Section shall not redisclose any information except as provided in this Act.” 740 ILCS 110/9(1). “Interagency disclosure of recipient information. For the purposes of continuity of care, . . . members of an interdisciplinary team, federally qualified health centers, or physicians or therapists . . . may disclose a recipient’s record or communications, without consent, to each other, but only for the purpose of admission, treatment, planning, coordinating care, discharge, or governmentally mandated public health reporting. . . .” 740 ILCS 110/9.2. “Disclosure for treatment and coordination of care. . . . (b) An interdisciplinary team treating a recipient may disclose the recipient's records without the recipient's consent to other members of the team. (c) The records that may be disclosed under this Section are services rendered, providers rendering the services, pharmaceuticals prescribed or dispensed, and diagnoses. All disclosures under this Section must be made in a manner consistent with existing federal and State laws and regulations, including the federal Health Insurance Portability and Accountability Act (HIPAA). . . .” 740 ILCS 110/9.4(b) and (c). I understand that Promise Healthcare may disclose my patient records without my consent to Community Elements as allowed by law. _______________________ _______________________ ______________________ Patient printed name Patient signature Date 819 Bloomington Road • Champaign, IL 61820
(217) 356-1558 • www.promisehealth.org
Consent Form Patient Information: First Name: _______________________ Last Name: _______________________ MI : _______ Date of Birth: __________________ SSN#: ____________________ Gender: □Male □Female Emergency Contact Name: _________________________________ Phone #: _____________ Sliding Fee Scale Discount Policy Promise Healthcare maintains a standard procedure for qualifying patients for sliding fee scale discounts for services provided. Sliding fee scale discounts are available to patients with income less than 200% of the federal poverty guidelines. Sliding fee scale discounts apply to all directly provided Promise Healthcare services, and for select ancillary services, as feasible, based on availability of resources and/or agreement by non-­‐Promise Healthcare providers providing services to Promise Healthcare patients. Authorization to receive treatment: I, _________________________________________, hereby authorize Promise Healthcare staff to provide care on my (or my dependent’s) behalf and to have access to information necessary for the delivery of services. I understand that in an emergency situation care will not be delayed, and this consent will be signed as soon as possible thereafter. I authorize Promise Healthcare staff to make appropriate referrals on my behalf. I understand that Frances Nelson works collaboratively with teaching institutions in the community and I may see a resident physician. I authorize the release of any medical information necessary to process my insurance claim(s). I authorize and request payment of medical benefits directly to Promise Healthcare. I understand that I am financially responsible for the copayment/deductible that my healthcare coverage indicates or if I don’t have insurance I will be responsible for the charges less any income-­‐based discounts I might qualify for. I understand that non-­‐payment may result in my account being forwarded to an outside collection agency. All collection fees incurred will be my responsibility. I agree that this authorization covers all medical services rendered until such agreement is revoked by me. I acknowledge receipt of the following forms and policies: Patient Rights, Privacy Notice, and Sliding Fee Scale Discount Policy __________________________________________ __________________________ Patient Name Date __________________________________________ __________________________ Patient/Guardian Signature Relationship to Patient 819 Bloomington Road • Champaign, IL 61820 (217) 356-­‐1558 • www.promisehealth.org Internal use only: Received on (date): ___________________ Processed on (date): __________________ Who processed request: _______________ Consent to Release Records Covered by the Mental Health and Developmental Disabilities Confidentiality Act To a Third Party As a patient, you may ask Promise Healthcare to release medical records in your designated record set to a third party, including records kept by an agency or therapist in the course of providing mental health or developmental disabilities services to you concerning you and the services provided. You may complete this form to give Promise Healthcare permission to use particular personal health information or disclose particular personal health information to a specified third party for a specified purpose. Your right to request release of records to a third party is subject to exceptions or specifications under federal and state law. You have the right to inspect and copy the information to be disclosed. Your Information: First Name: ___________________________________ Last Name: ___________________________________________ MI: _________ Date of Birth: _________________________ Address:__________________________________________________________________ City: _______________________________ Zip Code: ____________________ State: _________ Home #: ________________________ Cell #: _____________________________ Email address: _______________________________________________________________ Who has your health information? Who do you want to receive your health information? □ Promise Healthcare (Frances Nelson/SmileHealthy) □ Promise Healthcare (Frances Nelson/SmileHealthy) □ Other organization: ____________________________ (Name) ______________________________________________ (Street Address) ______________________________________________ (City) (State) (Zip) ______________________________________________ (Phone) □ Other organization: ____________________________ (Name) ______________________________________________ (Street Address) ______________________________________________ (City) (State) (Zip) ______________________________________________ (Phone) The purpose for the health information disclosure: □ Medical follow-­‐up □ Lawsuit □ Employment reasons □ Underwriting (insurance) □ Other (specify): _____________________________________ Only information relevant to the purpose for which disclosure is sought may be disclosed. Blanket consent to the disclosure of unspecified information shall not be valid. Advance consent may be valid only if the nature of the information to be disclosed is specified in detail and the duration of the consent is indicated. I want the following the health information released: □ All records in my designated record set, including medical and dental records that may contain sensitive information and records kept by Promise Healthcare or my therapist in the course of providing mental health or developmental disabilities services to me concerning me and the services provided, subject to exceptions or limitations under federal and state law. □ Office visit – mental health □ Labs □ Billing records (specify dates): ________________________ □ Other (specify): ____________________________________ Date(s) of treatment: _________________________________ If you want any of the following health information, then you must specifically check and initial next to the category of information: Your Initials ______ □Alcohol / drug abuse records* (see below) Your Initials ______ □ Genetics Your Initials ______ □HIV/AIDS/Sexually Transmitted Diseases This consent form expires on: ______________________________ (must be a specific calendar date, not a range or time period). Under Illinois law, if no calendar date is specified, then information may be released only on the day the consent form is received by the therapist. * Also, if you initialed release of alcohol / drug abuse records, then a consent form expiration date is required. As the patient, if I am under 18 years old, then Promise Healthcare will assist me in interpreting with health record without charge. As patient, Promise Healthcare will not limit or deny my access if I refuse Promise Healthcare’s health record interpretation assistance. the Under federal and state law, Promise Healthcare (or HealthPort, a company that processes health information requests for Promise Healthcare) may charge a fee to complete this request that is limited to the lower of: actual costs, or Illinois laws’ limits. I may ask Promise Healthcare for a fee estimate. Promise Healthcare will not charge any fee to the following agencies for one copy of the record: the Guardianship and Advocacy Commission; the agency designated by the Governor under Section 1 of the Protection and Advocacy for Developmentally Disabled Persons Act, or any other not-­‐for-­‐profit agency whose primary purpose is to provide free legal services or advocacy for the indigent and who has received written authorization from the recipient under Section 5 of the Mental Health and Developmental Disabilities Confidentiality Act to receive the patient’s records. Check below if you request Promise Healthcare (or HealthPort) to waive its fee: □ I request Promise Healthcare (or HealthPort) to waive its fee for one copy of my records because the agency receiving the records is one of the agencies above. Specify agency name: ________________________________________________. If you exercise your right to receive a copy of the records released to someone else under this form, then Promise Healthcare will not charge any fee to you to receive one copy of your records under the Mental Health and Developmental Disabilities Confidentiality Act, if you are indigent (low-­‐income or no-­‐income). Check below if you request Promise Healthcare (or HealthPort) to waive its fee: □ I request Promise Healthcare (or HealthPort) to waive its fee for one copy of the records that are released to someone else under this form. Attach income verification document(s). This authorization is voluntary and is not necessary to assure treatment. No agency or person who receives my health information under the Mental Health and Developmental Disabilities Confidentiality Act may re-­‐disclose my health information unless I specifically consent to the re-­‐disclosure. Alcohol / substance abuse records, HIV/AIDS records, and genetic records may not be re-­‐disclosed without my permission, unless authorized by law. I may revoke this consent in writing at any time. My written revocation must be witnessed by a person who can attest to my identity. I understand that my written revocation will not have any effect on the uses or disclosures of my health information that were made before Promise Healthcare received my written revocation. I have read and understand the contents of this form. ________________________________________________________ _______________________________________ Patient Signature (required) Date (required) I attest to the identity of the patient above. ________________________________________________________ _______________________________________ Witness Signature (required) Date (required) ________________________________________________________ Witness Printed Name (required) Promise Healthcare will record the following in the patient’s record: (1) A copy of this consent form, and (2) Enter a notation as to all actions taken. Promise Healthcare • Frances Nelson • SmileHealthy 819 Bloomington Road • Champaign, IL 61820 (217) 356-­‐1558 • www.promisehealth.org Promise Healthcare Medical Records -­‐ phone (217) 403-­‐5423, fax (217) 403-­‐5461 819 Bloomington Road, Champaign, IL 61820 – www.promisehealth.org Family, Friends and Others Involved in Your Care Patient Name: ____________________________________________________ Date of Birth: _________________ Phone #: ________________________ Promise Healthcare may discuss your care including appointment times, diagnoses, medications, concerns, and plan of care with those involved in your care or its payment. We will not discuss mental health, developmental disabilities, alcohol/drug abuse, genetics, or HIV/AIDS/STDs without an additional release. To assist us in knowing the family, friends and others involved in your care, please list them below. ________________________ ________________________ _________________________ Name Relationship to patient Phone ________________________ ________________________ _________________________ Name Relationship to patient Phone ________________________ ________________________ _________________________ Name Relationship to patient Phone ________________________ ________________________ _________________________ Name Relationship to patient Phone ________________________ ________________________ _________________________ Name Relationship to patient Phone [ ] This authorization does not expire; or [ ] I only want to involve those listed above for a limited amount of time. Their assistance is only needed through ____________________________________________________________ . I may cancel this authorization in writing at any time. ______________________________________ Signature of Patient/Parent/Guardian _______________________________ Date Promise Healthcare Medical Records -­‐ phone (217) 403-­‐5423, fax (217) 403-­‐5461 819 Bloomington Road, Champaign, IL 61820 – www.promisehealth.org Medical Cancellation Policy Make an Appointment. Keep an Appointment TO GIVE OUR PATIENTS THE BEST CARE POSSIBLE WE NEED YOU TO KEEP YOUR APPOINTMENT AND TO BE ON TIME If you cannot attend your appointment: • You must give a 24 hour notice of cancellation. • If you call less than 24 hours before the appointment, it will be considered a no-­‐show. • If you miss and do not cancel, you will be marked as a no-­‐show. After three no-­‐shows you will be placed on a WALK IN AND WAIT status. That means that we will no longer make appointments for you, but we will see you if you come in and there is time for one of the clinical staff to see you. WALK IN AND WAIT does NOT guarantee that a provider will see you. Your status as a WALK IN AND WAIT patient will remain in effect for one year. To be considered for an early status change, you may •
Submit a letter to the Clinical Services Manager requesting re-­‐admission to appointment status. •
The letter must explain the reasons why you did not keep your missed appointments. •
The decision on your re-­‐admission will be made by the Clinical Services Manager. PLEASE MARK YOUR CALENDAR AND ARRIVE ON TIME I have read this policy and understand my responsibility. ____________________________ Signature ____________________________ Printed Name 819 Bloomington Road • Champaign, IL 61820 (217) 356-­‐1558 • www.promisehealth.org Patients’ Rights
As an individual receiving services through Promise Healthcare, you have the right:
To receive services regardless of your age, race, color, sexual orientation, religion, marital
status, gender, national origin or sponsors.
To be treated with consideration, respect and dignity, including privacy treatment.
To be informed of services available at our health center.
To be informed of provisions for off-hour emergency coverage.
To be informed of the charges for services, eligibility for third-party reimbursements and,
when applicable, the availability of free or reduced cost care.
To receive an itemized copy of your account statement upon request.
To obtain from our health center, complete and current information concerning your
diagnosis, treatment and prognosis in terms you can be reasonably expected to understand.
To refuse to participate in experimental research.
To receive from your clinician, information necessary to give informed consents prior to the
start of any nonemergency procedure and/or treatment. An informed consent shall include,
as a minimum, the provision of information concerning the specific procedure and/or
treatment, the reasonable foreseeable risks involved, and alternatives for care or treatment,
if any, as a reasonable medical practitioner under similar circumstances would disclose in a
manner permitting you to make a knowledgeable decision.
To refuse treatment to the extent permitted by law and to be fully informed of the medical
consequences of this action.
To voice grievances and recommend changes in policies and services to the agency staff, the
administrator of the agency, or the Department of Health without fear of reprisal.
To express complaints about the care and services and to have the health center investigate
such complaints. Promise Healthcare is responsible for providing you or your designee with a
written response within 30 days, if requested, indicating the findings of the investigation. The
agency is also responsible for notifying you or your designee that if you are not satisfied by
the agency response, you may complain to the Illinois State Department of Health’s Office of Health Systems Management.
To have the privacy and confidentiality of all information and records pertaining to your
treatment at Promise Healthcare facilities.
To approve or refuse the disclosure information of the contents of your medical record to
any health care practitioner and/or health care facility except as required by law or thirdparty payment contract.
To access your medical record.
819 Bloomington Road • Champaign, IL 61820
(217) 356-1558 • www.promisehealth.org
Promise Healthcare Notice of Privacy Practices This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record Ÿ You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We may ask you to make the request in writing. Ÿ We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-­‐based fee. Ask us to correct your medical record Ÿ You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. Ÿ We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications Ÿ You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. Ÿ We will say “yes” to all reasonable requests. Ask us to limit what we use or share Ÿ You can ask us not to use or share certain health information for treatment, payment, or our operations. • We are not required to agree to your request, and we may say “no” if it would affect your care. • If you pay for a service or health care item out-­‐ of-­‐pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. • We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-­‐based fee if you ask for another one within 12 months. Get a copy of this privacy notice • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated • You can complain if you feel we have violated your rights by contacting us using the information on last page of this notice. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-­‐877-­‐696-­‐ 6775, or visiting www.hhs.gov/ocr/privacy/hipaa/ complaints/. • We will not retaliate against you for filing a complaint. Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases you have both the right and choice to tell us to: • Share information with your family, close friends, or others involved in your care. 819 Bloomington Road • Champaign, IL 61820 (217) 356-­‐1558 • www.promisehealth.org • Share information in a disaster relief situation. If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: • Marketing purposes • Sale of your information • Most sharing of psychotherapy notes In the case of fundraising: Ÿ We may contact you for fundraising efforts, but you can tell us not to contact you again. Other Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you • We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. • We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services. • We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. The examples used in this Notice of Privacy Practices are illustrations only and not meant to be a complete list. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues • We can share health information about you for certain situations such as: • Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety Do research • We can use or share your information for health research. Comply with the law • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests • We can share health information about you with organ procurement organizations. Work with a medical examiner or funeral director • We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests • We can use or share health information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions • We can share health information about you in response to a court or administrative order, or in response to a subpoena. Federal law privacy protections and state law privacy protections HIPAA generally does not preempt or override other laws that give people greater privacy protections. If any applicable state or federal law requires us to provide you with more privacy protections, then we must follow that law in addition to HIPAA. 819 Bloomington Road • Champaign, IL 61820 (217) 356-­‐1558 • www.promisehealth.org Some types of health information may have additional protection under federal or state law. For example, some genetic test results, mental health records, HIV / AIDS test results, educational records, and federally assisted alcohol and substance abuse treatment programs are subject to special restrictions on our use and disclosure under various laws. Our Responsibilities •
We are required by law to maintain the privacy and security of your protected health information. •
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. •
We must follow the duties and privacy practices described in this notice and give you a copy of it. •
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/ understanding/consumers/noticepp.html. Changes to the Terms of This Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. This Notice of Privacy Practices applies to the following organizations: This notice covers Promise Healthcare's services which includes: Ÿ Frances Nelson Health Center, Ÿ SmileHealthy Dental Center, Ÿ Medicaid and Health Insurance Marketplace Outreach and Enrollment, Ÿ Promise Healthcare at the Community Resource Center, Ÿ Promise Healthcare at Community Elements, and Ÿ SmileHealthy Mobile, Head Start & Education. If you have any questions or would like further information about this Notice of Privacy Practices, you can write or call Promise Healthcare’s Privacy Officer: Promise Healthcare Privacy Officer 819 Bloomington Road Champaign, IL 61820 www.promisehealth.org [email protected] 217-­‐356-­‐1558 Effective Date: July 1, 2015. 819 Bloomington Road • Champaign, IL 61820 (217) 356-­‐1558 • www.promisehealth.org