NEW PATIENT REGISTRATION

Please read this Agreement carefully: It is a legally binding contract. By accepting it, you are electronically signing and agreeing to be bound by this New Patient Registration and each of the demarcated documents contained herein include the Notice of Privacy Practices, General Consent and Patient Rights and Responsibilities. If you do not wish to be bound by this Agreement, you may not receive services provided by Magenta Health.

ORGANIZED HEALTH CARE ARRANGEMENT

In an effort to improve quality of care and reduce costs for patients of the participating organizations identified below (the “OHCA Participants”), an Organized Health Care Arrangement (OHCA) has been formed by the OHCA Participants. An OHCA is a relationship recognized by HIPAA (defined below) allowing the OHCA Participants to share Protected Health Information (PHI), as defined under HIPAA, with and among the OHCA Participants.

An OHCA also offers several advantages that include: development of patient care programs; facilitating the aggregation of data for the treatment of participating patient populations; improves the quality of care; reduces costs; and allows the patient’s care to be coordinated and tailored based upon the individual’s health care needs. The OHCA:

  • Involves more than one Covered Entity (CE) participant;
  • Requires that participating CEs publicly acknowledge participating in a joint agreement; or
  • Requires that the CEs participate in joint activities that include quality assessment and improvement activities.

What does this mean for you?

It means that the OHCA Participants may share your medical information with each other as needed for the purposes of providing your treatment and coordinating on payment and health care operations. It also means that the OHCA Participants may share your medical information for joint quality assessment and improvement activities.

The OHCA Participants remain committed to providing a strong foundation for member health care needs. The partnership through the OHCA will further allow the OHCA Participants to honor the commitment to sustain valued benefits while continuing to enhance the care delivered to our patients and members.

OHCA Participants, as of the Effective Date below, include:

 

Magenta Health, Inc.

W2Locums (dba Florence Medical Group)

Magenta Health, Inc. hereby affirms that it is a CE able to participate in an OHCA. W2Locums hereby affirms that it is a CE able to participate in an OHCA. Any OHCA Participants who are added to this notice at any time in the future must make similar confirmations of their status as a CE.

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.

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 a copy of your paper or electronic medical record

  • 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 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.

Correct your paper or electronic medical record

  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we will tell you why in writing within 60 days.

Request confidential communication

  • 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.
  • We will say “yes” to all reasonable requests.

 Ask us to limit the information we share

  • 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 or for other reasons.
  • If you pay for a service or healthcare 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 your 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 healthcare operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but may 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 believe your privacy rights have been violated

  • You can complain if you feel we have violated your rights. You can file a complaint with the Magenta Healthcare Privacy Office at (210) 938-4907, toll free at (866) 432-4318, or by email at privacyoffice@heb.com.
  • 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 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;
  • Share information in a disaster relief situation;
  • Include your information in a hospital directory; however, Magenta Health does not create or manage a hospital directory;
  • Contact you for fundraising efforts.

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:

  • We may only use and disclose your health information for marketing purposes with your written authorization, unless the communication is a face-to-face communication made by us to you or a promotional gift of nominal value provided to you by us.

OUR 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 healthcare provider discussing your treatment or providing your information to another provider for treatment purposes.
    • Example: A pharmacist fulfilling your prescription asks your doctor about your prescription.

Run our organization

  • 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.
    • Example: We access your health information to ensure our staff is performing well.
    • Example: The pharmacy contacts you to inform you about certain health-related products or services that we offer.

Bill for your 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.
  • 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: hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Make you Aware of Other Healthcare-related Services

  • We can use your health information to make you aware of other healthcare products or services, such as registered dietitians, weight loss or other classes, or disease-state or education classes. This is only to provide information to you. As it relates to sharing information regarding other healthcare-related services, your information will not be shared with other healthcare providers or healthcare services who are not treating you without your consent.
  • If you do not want us to do this, opt out by calling us at 1-210-938-4907 or toll-free at 1-866-432-4318 or emailing us at privacyoffice@heb.com.

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 or treatment;
    • 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 non-identifiable 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.

OUR RESPONSIBILITIES

  • We are required by law to maintain the privacy and security of your protected health information.
  • When a state law requires us to impose stricter standards to protect your health information, we will follow the state law in addition to the privacy practices described in this notice.
  • We will let you know promptly if an unmitigated 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.

For More Information or to Report a Problem

If you have questions or would like additional information, please contact:

Magenta Health, Inc.

646 S. Flores

San Antonio, Texas, 78204

(210) 938-4907

 

Effective Date of this Notice: January 1, 2019.

Effective Date: January 1, 2019