Assignment of Benefits: The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to Upper Valley Behavioral Health
LLC. I understand that I am financially responsible for any balance. I also authorize Upper Valley Behavioral Health LLC, its related companies, or insurance company to
release medical information required to process claims.
Notice of Privacy Practices: I have read or been offered a copy of Upper Valley Behavioral Health LLC's Notice of Privacy Practices (NPP), which explains how my medical
information will be used and disclosed. I authorize the release of my medical information necessary to provide care and bill on my behalf. I understand I am entitled to a
copy of the NPP.
Authorizations: I authorize medical treatment of the person named above and agree to pay all fees and charges for such treatment. I understand that medical treatment
may include a review of medical history and discussion of reason for visit. I authorize Upper Valley Behavioral Health LLC to disclose complete information concerning medical
finding and treatment of the undersigned, from the initial office visit until date of the conclusion of such treatment, to those individuals who, in Upper Valley Behavioral
Health LLC's determination, are required to receive such information for the purpose of medical treatment, medical quality assurance, peer review, and if applicable to process the insurance claim for services rendered at Upper Valley Behavioral Health LLC.
Consent for Communication: I understand Upper Valley Behavioral Health LLC will send appointment reminders and information on services via telephone, email and/or text
message based on the contact information I have provided. I understand that I will have the option to opt out of future text/email reminders.
Payment Policy: Payment is due at time of service, including copays and prior balance due. I understand I am responsible for all charges for services rendered on my
behalf, or on behalf of my dependents, less any amount paid by insurance to Upper Valley Behavioral Health LLC and its related companies.
Late or Missed Appointment Policy: We require a 24-hour cancellation notice if you are not able to keep your appointment. Clients who no-show more than 3 times may be
asked to leave the practice. Families who perform a no-show for a double-visit will not be allowed to schedule double-visit appointments again. If you arrive more than 15 minutes late for an appointment you may be asked to reschedule the appointment, or you may be seen that day when we are able to accommodate you.
Legal: This form applies to Upper Valley Behavioral Health LLC.
Patient Rights: I have read or been offered a copy of Upper Valley Behavioral Health LLC Patient Rights.
Patient Rights Document Received:ReceivedDeclined
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
This practice uses and discloses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.
This notice describes our privacy practices. You can request a copy of this notice at any time. For more information about this notice or our privacy practices and policies, please contact the person listed below.
Treatment, Payment, Health Care Operations
We are permitted to use and disclose your medical information to those involved in your treatment. For example, the provider in this practice is a specialist. When we provide treatment, we may request that your primary care provider share your medical information with us. Also, we may provide your primary care provider information about your particular condition so that he or she can appropriately treat you for other medical conditions, if any.
Your care may also require the involvement of another specialist. When we refer you to another specialist, we will share some or all of your medical information with that provider to facilitate the delivery of care.
We are permitted to use and disclose your medical information to bill and collect payment for the services provided to you. For example, we may complete a claim form to obtain payment from your insurer or HMO. The form will contain medical information, such as a description of the medical service provided to you, that your insurer or HMO needs to approve payment to us.
Health Care Operations
We are permitted to use or disclose your medical information for the purposes of health care operations, which are activities that support this practice and ensure that quality care is delivered.
For example, we may engage the services of a professional to aid this practice in its compliance programs. This person will review billing and medical files to ensure we maintain our compliance with regulations and the law.
Another example, we may ask another healthcare professional to review this practice’s charts and medical records to evaluate our performance so that we may ensure that only the best health care is provided by this practice.
Disclosures That Can Be Made Without Your Authorization
There are situations in which we are permitted by law to disclose or use your medical information without your written authorization or an opportunity to object. In other situations, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization, in writing, to stop future uses and disclosures. However, any revocation will
not apply to disclosures or uses already made or taken in reliance on that authorization.
Public Health, Abuse or Neglect, and Health Oversight
We may disclose your medical information for public health activities. Public health activities are mandated by federal, state, or local government for the collection of information about disease, vital statistics (like births and death), or injury by a public health authority. We may disclose medical information, if authorized by law, to a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. We may disclose your medical information to report reactions to medications, problems with products, or to notify people of recalls of products they may be using.
We may also disclose medical information to a public agency authorized to receive reports of child abuse or neglect in accordance with State and Federal Law. Regulations also permit the disclosure of information to report abuse or neglect of elders or the disabled.
We may disclose your medical information to a health oversight agency for those activities authorized by law.
Examples of these activities are audits, investigations, licensure applications and inspections which are all government activities undertaken to monitor the health care delivery system and compliance with other laws, such as civil rights laws.
Legal Proceedings and Law Enforcement
We may disclose your medical information in the course of judicial or administrative proceedings in response to an order of the court (or the administrative decision-maker) or other appropriate legal process. Certain requirements must be met before the information is disclosed.
If asked by a law enforcement official, we may disclose your medical information under limited circumstances provided
that the information:
- Is released pursuant to legal process, such as a warrant or subpoena;
- Pertains to a victim of crime and you are incapacitated;
- Pertains to a person who has died under circumstances that may be related to criminal conduct;
- Is about a victim of crime and we are unable to obtain the person’s agreement;
- Is released because of a crime that has occurred on these premises; or
- Is released to locate a fugitive, missing person, or suspect.
We may also release information if we believe the disclosure is necessary to prevent or lessen an imminent threat to the health or safety of a person.
We may disclose your medical information in accordance with workers’ compensation law.
If you are an inmate or under the custody of law enforcement, we may release your medical information to the correctional institution or law enforcement official. This release is permitted to allow the institution to provide you with medical care, to protect your health or the health and safety of others, or for the safety and security of the institution.
Military, National Security and Intelligence Activities, Protection of the President
We may disclose your medical information for specialized governmental functions such as separation or discharge from military service, requests as necessary by appropriate military command officers (if you are in the military), authorized national security and intelligence activities, as well as authorized activities for the provision of protective services for the President of the United States, other authorized government officials, or foreign heads of state.
Research, Organ Donation, Coroners, Medical Examiners, and Funeral Directors
When a research project and its privacy protections have been approved by an Institutional Review Board or privacy board, we may release medical information to researchers for research purposes. We may release medical information to organ procurement organizations for the purpose of facilitating organ, eye, or tissue donation if you are a donor. Also, we may release your medical information to a coroner or medical examiner to identify a deceased or a cause of death. Further, we may release your medical information to a funeral director where such a disclosure is necessary for the director to carry out his duties.
Required by Law
We may release your medical information where the disclosure is required by law.
Your Rights Under Federal Privacy Regulations
The United States Department of Health and Human Services created regulations intended to protect patient privacy as required by the Health Insurance Portability and Accountability Act (HIPAA). Those regulations create several privileges that patients may exercise. We will not retaliate against a patient that exercises their HIPAA rights.
You may request that we restrict or limit how your protected health information is used or disclosed for treatment, payment, or healthcare operations. We do NOT have to agree to this restriction, but if we do agree, we will comply with your request except under emergency circumstances.
To request a restriction, submit the following in writing: (a) The information to be restricted, (b) what kind of restriction you are requesting (i.e. on the use of information, disclosure of information or both), and (c) to whom the limits apply. Please send the request to the address and person listed below.
You may also request that we limit disclosure to family members, other relatives, or close personal friends that may or may not be involved in your care.
Receiving Confidential Communications by Alternative Means
You may request that we send communications of protected health information by alternative means or to an alternative location. This request must be made in writing to the person listed below. We are required to accommodate only reasonable requests. Please specify in your correspondence exactly how you want us to communicate with you and, if you are directing us to send it to a particular place, the contact/address information.
Inspection and Copies of Protected Health Information
You may inspect and/or copy health information that is within the designated record set, which is information that is used to make decisions about your care. Your state law may require that requests for copies be made in writing and we ask that requests for inspection of your health information also be made in writing. Please send your request to the person listed below.
We can refuse to provide some of the information you ask to inspect or ask to be copied if the information:
- Includes psychotherapy notes.
- Includes the identity of a person who provided information if it was obtained under a promise of confidentiality.
- Is subject to the Clinical Laboratory Improvements Amendments of 1988.
- Has been compiled in anticipation of litigation.
We can refuse to provide access to or copies of some information for other reasons, provided that we provide a review of our decision on your request. Another licensed health care provider who was not involved in the prior decision to deny access will make any such review.
Federal and state law requires that we are ready to provide copies or a narrative within a timely manner. We will inform you of when the records are ready or if we believe access should be limited. If we deny access, we will inform you in writing.
HIPAA permits us to charge a reasonable cost based fee. Each Medical Board has set limits on fees for copies of medical records that under some circumstances may be lower than the charges permitted by HIPAA. In any event, the lower of the fee permitted by HIPAA or the fee permitted by the practice’s State Medical Board will be charged.
Amendment of Medical Information
You may request an amendment of your medical information in the designated record set. Any such request must be made in writing to the person listed below. We will respond within 60 days of your request. We may refuse to allow an amendment if the information:
- Wasn’t created by this practice or the providers here in this practice.
- Is not part of the Designated Record Set?
- Is not available for inspection because of an appropriate denial.
- If the information is accurate and complete.
Even if we refuse to allow an amendment you are permitted to include a patient statement about the information at issue in your medical record. If we refuse to allow an amendment, we will inform you in writing. If we approve the amendment, we will inform you in writing, allow the amendment to be made and tell others that we know have the incorrect information.
Accounting of Certain Disclosures
The HIPAA privacy regulations permit you to request, and us to provide, an accounting of disclosures that are other than for treatment, payment, health care operations, or made via an authorization signed by you or your representative. Please submit any request for an accounting to the person listed below. Your first accounting of disclosures (within a 12 month period) will be free. For additional requests within that period we are permitted to charge for the cost of providing the list. If there is a charge, we will notify you and you may choose to withdraw or modify your request before any costs are incurred.
Appointment Reminders, Treatment Alternatives, and Other Health-related Benefits
We may contact you by telephone, mail, or both to provide appointment reminders, information about your laboratory results, treatment alternatives, or other health-related benefits and services that may be of interest to you.
If you are concerned that your privacy rights have been violated, you may contact the person listed below. You may also send a written complaint to the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint with the government or us. The contact information for the United States Department of Health and Human Services is:
U.S. Department of Health and Human Services
7500 Security Blvd., C5-24-04
Baltimore, MD 21244
Our Promise to You
We are required by law and regulation to protect the privacy of your medical information, to provide you with this notice of our privacy practices with respect to protected health information, and to abide by the terms of the notice of privacy practices in effect.
Questions and Contact Person for Requests
If you have any questions or want to make a request pursuant to the rights described above, please contact:
Upper Valley Behavioral Health LLC
5690 Santa Teresita Dr., Suite A-2
Santa Teresa, NM 88008-9211
Phone: (575) 332-4115 or Fax: (915) 243-6005
This notice is effective on the following date: January 1, 2019
We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen.