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AllCheer Client Privacy Notice and Health Information Consent Form

Latest Version: v1.2 October 21, 2023

Effective Date: October 21, 2023

 

At AllCheer, your privacy and the security of your health information are of utmost importance to us. This Privacy Notice outlines how we handle your Protected Health Information (PHI) in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and other relevant privacy laws. Please review this notice carefully and sign at the bottom to acknowledge your understanding and agreement.

 

1. How We Use and Disclose Your PHI:

We use and disclose PHI for treatment, payment, and healthcare operations purposes. For example, PHI may be shared with other healthcare providers for treatment coordination, or used for billing purposes with your insurance provider. We may also use PHI to improve our healthcare services, train our staff, and comply with legal and regulatory requirements. AllCheer will limit the release of all PHI to the minimum needed for what the purpose requires.

 

2. Your Rights Regarding PHI:

You have the following rights concerning your PHI:

  • Right to Access: You can request access to your PHI in our records, and obtain copies for a reasonable fee.

  • Right to Amend: You can ask us to amend your health information if you believe it is incorrect or incomplete.

  • Right to an Accounting of Disclosures: You can request a list of the disclosures we have made of your PHI.

  • Right to Request Restrictions: You can request a restriction or limitation on the PHI we use or disclose, in writing. We will make reasonable efforts to adhere to the requested restrictions, where feasible. We are not obligated to agree to all restrictions, if it hinders our ability to provide you medically necessary services or our ability to collect payment for services through your insurance provider

  • Right to Confidential Communications: You can request that we communicate with you about medical matters in a certain way or at a certain location unless it puts undue burden on our operations or AllCheer staff, as determined at our own discretion.

 

3. Our Obligations:

We are required by law to:

  • Maintain the privacy of your PHI

  • Provide you with this notice of our legal duties and privacy practices with respect to PHI

  • Abide by the terms of this Privacy Notice currently in effect

  • Notify you if there is a breach of your unsecured PHI

 

4. Electronic Delivery of Privacy Notice:

Electronic Receipt: By providing your email address below you acknowledge receipt of this notice electronically via email.

Request for Paper Copy: If you wish to receive a paper copy of this notice, you may request one at any time, even if you have agreed to receive this notice electronically. Please contact our Privacy Officer using the details provided in section 6.

 

5. Changes to This Notice:

We reserve the right to change our privacy practices and the terms of this notice at any time. Any changes will apply to the PHI we already hold, as well as new information after the change occurs. A current version of this notice will be posted on our website and can be accessed using the following url: https://www.allcheer.org/allcheerclientprivacynotice

 

6. Complaints:

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. You will not be penalized or retaliated against for filing a complaint.

 

7. Contact Information:

For any inquiries, or to request a paper copy of this notice, please contact:

Privacy Officer: Deb Bardhan, 

Address: 548 Market Street, Suite 99187, San Francisco, CA 94104

Phone: +1 (415) 275 1838

Email: operations@allcheer.org

 

Acknowledgment of Receipt of Privacy Notice:

I acknowledge that I have received and reviewed the AllCheer Client Privacy Notice and Health Information Consent Form.

 

Your Name (Print): __________________________

 

Your Signature: _____________________________

 

Date: ___________________

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