Jacksonville Child Intake Form

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Step 1
Patient Information
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Step 2
Insurance Information
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Step 3
Guardian
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Step 4
Symptoms
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Step 13
General Consent for Treatment
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Step 14
PHI Permission
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Step 15
General Policies
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Step 16
Insurance Assignments
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Step 17
Financial Agreement
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Step 17
Financial Agreement
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Step 17
Financial Agreement
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Step 17
Financial Agreement
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Step 19
Notice of Privacy Practices

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*Patient Name

Prefers to be called

Ethnicity

Choose One

Female

Male

Unknown

Prefers to be recognized as

Female

Male

Preferred Language

Current Diagnosis (if any)

Name (Person completing this form)

Relationship to Patient

Address

Primary Phone

Secondary Phone

Child's Primary Physician

*Phone Number

Child's Referring Physician

Specialty

Emergency Contact

Relationship

Emergency Contact Phone

Primary Insurance Type

Member ID Number

Group Number

Policy Holder’s Name

Policy Holder’s DOB

Policy Holder’s Social Security Number

Secondary Insurance Type

Member ID Number (Secondary Insurance)

Group Number (Secondary Insurance)

Policy Holder’s Name (Secondary Insurance)

Policy Holder’s DOB (Secondary Insurance)

Policy Holder’s Social Security Number (Secondary Insurance)

Guardian Name

Occupation

Home Phone

Guardian Social Security Number

Marital Status

Guardian Relationship to Patient

Guardian Date of Birth

Cell Phone

Work Phone

Guardian Email

Secondary Guardian Name

Secondary Guardian Occupation

Secondary Guardian Phone

Secondary Guardian Social Security Number

Secondary Guardian Marital Status

Secondary Guardian Relationship to Patient

Secondary Guardian Date of Birth

Secondary Guardian Cell Phone

Secondary Guardian Work Phone

Secondary Guardian Email

*Elite DNA Therapy Services, LLC may contact guardian, emergency contact or guarantor for verify purposes or in case of
emergency.

Please describe your primary concerns. (How long have you noticed this?)

Have you already tried to address these concerns?

Yes

Were the efforts effective?

Yes

If there was an event that caused you to seek treatment now; what is it?

Current Symptoms Checklist:

Personal/Social Adjustment

Unduly sad

Overly anxious, shy, or withdrawn

Verbally aggressive

Temper tantrums

Physically aggressive

Harms self or others (suicidal or homicidal)

Disturbing habits or mannerisms

Problems with the law

Strange or bizarre behavior

Paranoia or hallucinations

Problems in peer relationships

Drug or alcohol problems

Other

Family Adjustment

Parent-child problem

Separation from parent

Marital conflict

Co-parenting problems

Sibling conflict

Domestic violence

History of loss or abandonment

Neighborhood difficulties

Mother experiencing difficulties

Father experiencing difficulties

Sibling experiencing difficulties

Drug or alcohol problems in family

Other

School Adjustment

Academic problems

Difficulty with peers

Difficulty with authority

Poor attendance/reluctance to go to school

Behavior problems

Learning disabilities

Attention problems

Aches and pains related to school

Other

Physical/Developmental Factors

Eating

Sleeping

Toileting

Grooming

Language or Speech

Perceptual/visual functions

Motor coordination problems

Other

Elite DNA Therapy Services, LLC
General Consent for Treatment

*Patient Name

*Date of Birth

Consent for Treatment

I hereby voluntarily give my consent for myself, my child, or my family to receive one or more of the following services or treatments provided by Elite DNA Therapy Services, LLC: Psychiatry, Psychotherapy, Medication Management, Occupational Therapy (OT), Speech Therapy (ST), Advanced Behavioral Analysis (ABA), Transcranial Magnetic Stimulation (TMS), Mental Health, or Substance Abuse and Addiction Medicine services, all within the professional medical judgement and discretion of Elite DNA Therapy Services, LLC’s doctors, nurse practitioners, and staff. I further consent to the collection and use of past and current medical and medicine history of the patient, patient’s family, patient’s providers, including pharmacies from which prescriptions have been obtained. I consent to the use of photography for purposes of verifying identification of patients and/or identifying accompanying persons. Because I have the right to refuse services at any time, I understand and agree that my or my family’s continued participation in services or treatments offered by Elite DNA Therapy Services, LLC implies informed consent. If I choose to revoke this consent, I understand that providers and/or clinic staff may not be able to provide to me, my child, or family members necessary services and treatments that have been recommended. I further understand that Elite DNA Therapy Services, LLC participates in educational programs and that students in these affiliated programs may be involved in care provided.

*Initials

I understand that potential benefits of undergoing services offered by Elite DNA Therapy Services, LLC may include improvement in functioning of myself or child and/or an increased understanding of myself and/or child. I understand that potential risks may include possible disagreement with opinions offered to me, and possible emotional distress concerning my situation. I understand that alternative procedures may include services provided by other psychologists, psychiatrists, or mental health professionals.

*Initials

I understand that while the evaluation and/or treatment will be based upon known principles and research, the practice is not an exact science. I acknowledge that no guarantees have been made to me concerning the results of evaluations and/or treatments or services provided by Elite DNA Therapy Services, LLC.

*Initials

I verify that I am the patient OR patient’s legal guardian per Florida State Statute Chapter 744 for the above and furthermore certify that the information, records, and other documents I have provided to Elite DNA Therapy Services, LLC (either verbally or in writing) are accurate to the best of my knowledge.

*Initials

I hereby acknowledge that I have reviewed the Notice of Privacy Practice(NPP) and the Patients’ Rights and Responsibilities documents. I can request copies. Elite DNA Therapy Services, LLC must post NPPs. Signed copies of consents, agreements, and authorizations can be used in place of original scanned into medical record chart.

By signing below, I am agreeing to consent for treatment and my understanding of the information described in this document. I have read this consent and have been able to ask questions.

*Name

Relationship to Patient

*Signature of Patient or Patient Representative

*Date

Elite DNA Therapy Services, LLC
Permission to Discuss Protected Health Information (PHI) Others Who are Involved in Your Healthcare (Not to Be Used as Authorization to Release Information)

*Patient Name

*Date of Birth

I hereby permit Elite DNA Therapy Services, LLC to share specific information described below, only for the purposes and persons involved in my healthcare.

Description of the specific information to be discussed:

Appointment Date/Times

Diagnosis

Medications Lab Tests/Results

Summary of Medical Record

Pick Up Prescriptions

Care Plan

Medications Lab Tests/Results

Genetic Testing Results

Other (specify):

Indicate Confidential Information you don’t want discussed:

Mental Health

Medication

HIV information

Alcohol/Drug Information

Information provided to:

Name

Address:

Phone Number

Relationship to Patient

Name

Address:

Phone Number

Relationship to Patient

It is my responsibility to inform Elite DNA Therapy Services, LLC of changes and to revoke and complete another form.

I understand that:

This document does not dictate that our providers will initiate conversations or other methods to share information with persons listed above. If those persons wished to be involved, then it is their duty to initiate involvement, and if time and circumstances permit, then Elite DNA Therapy Services, LLC will do our best to comply to your wishes.

I may revoke this permission in writing by contacting our office manager or Privacy Officer.

Information shared may be subject to re-disclosure by the recipient and no longer be protected under HIPAA

This document is intended to relieve burden of our staff to know to whom you want to involve in this patient’s care. It is not mandatory to complete.

This document is not an authorization to release protected health information (PHI).

Information Excluded from the Right of Access: Psychotherapy notes, which are the personal notes of a mental health care provider documenting or analyzing the contents of a counseling session, that are maintained separately from the rest of the patient’s medical record. (45 CFR 164.524(a)(1)(i) and 164.501)

*Name

Relationship to Patient

*Signature of Patient or Patient Representative

*Date

Elite DNA Therapy Services, LLC
General Policies, Insurance Assignments, and Financial Agreement

*Patient Name

*Date of Birth

General Policies

*Initials

Emergency Services – Elite DNA Therapy Services, LLC is not a 24‐clinic and WE DO NOT PROVIDE EMERGENCY SERVICES. For emergencies call 911 or go to the nearest emergency room. For non‐life‐threatening after‐hours services, please call the office and follow prompts.

*Initials

Missed/Cancelled Appointments –A patient who fails to appear or cancels less than 24 hours in advance of an appointment may be subject to a $40 fee and may be discharged. The first appointment with the psychiatrist for an initial evaluation is critical. If you miss this evaluation you may not be able to reschedule the appointment for a 6‐month period. Please remember to reschedule ahead of time and we will attempt to accommodate your requests. Since “things happen,” patients will be permitted to miss one appointment in a 6‐month period without being penalized. However, please know that repeated “no‐shows” may jeopardize your ability to receive treatment.

*Initials

Lateness–Due to stringent billing requirements, we will be unable to see patients who are late for their appointment. Please call to let us know if you are running late and we will attempt to reschedule your appointment, as needed. However, you may be subject to a $40 fee or suspension of services if you are not able to maintain your appointments.

*Initials

Absence for More than 6 Months –If you cancel or miss your appointments for longer than a 6‐month period, you may be considered a new patient and another intake appointment may be necessary. Also, you may be placed on a waiting list.

*Initials

Communications – You understand that you may receive calls from Elite DNA Therapy Services, LLC or third‐party business associates for purposes of including, but not limited to, results in communication, patient surveys, and debt collection using the phone numbers, including wireless numbers you have provided. I understand I may be charged for such calls by my wireless carrier and that such calls may be generated by an automated dialing system.

*Initials

Confidentiality and Release of Protected Health Information (PHI) – All information disclosed within sessions is confidential and may not be revealed to anyone outside of the Elite DNA Therapy Services, LLC without written permission, except for disclosures as required by law. The law does require clinicians to report to the authorities any reasonable suspicions of child or elder abuse, or danger of harm to self and/or to others unless protective measures are taken. To the extent necessary to determine insurance benefits or liability for payment and to obtain reimbursement, Elite DNA Therapy Services, LLC may disclose portions of the patient’s medical record and account file to any person or corporation that may be liable for all or any portion of the patient’s charges, including but not limited to insurance companies, health care service plans or workers’ compensation carriers. Elite DNA Therapy Services, LLC may disclose information to referring providers following the minimum necessary rule.

Elite DNA Therapy Services, LLC
General Policies, Insurance Assignments, and Financial Agreement

Insurance Assignments

*Initials

Fees for Clinical Services –At Elite DNA Therapy Services LLC, we accept many insurance plans, single case agreements, and private pay. Please inquire about our fees, as the rates may be different depending on which provider you are seeing. Please know that you may be billed for telephone calls, written reports, or other services that specifically require the provider’s time outside of scheduled appointments.

*Initials

Assignment of Insurance Benefits –In consideration of services rendered, I hereby transfer and assign to Elite DNA Therapy Services, LLC all rights, title, and interest in any payment due to me for services described herein as provided in the above‐mentioned policy or policies of insurance.

*Initials

Medicare / Medicaid –I certify that the information given to me in applying for payment under Title XVIII/XIX of the Social Security Act is correct. I authorize that any holder of medical or other information about me may send to responsible carriers, or their intermediaries, any information needed for this or a related Medicare/Medicaid claim. I hereby certify all insurance pertaining to treatment shall be assigned to the clinic treatment me.

Elite DNA Therapy Services, LLC
General Policies, Insurance Assignments, and Financial Agreement

Financial Agreement

*Initials

Payment Responsibility –I understand that insurance claims are filed as a courtesy. If a claim is denied for any reason, I am responsible for payment. Insurance is considered a method of reimbursing the provider for services rendered to the patient. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charges. I authorize direct payment to be made to Elite DNA Therapy Services, LLC for all services and treatments rendered. I understand if any services or treatment charges are not covered by my insurance carrier or my eligibility cannot be verified, I am responsible for all charges incurred. Furthermore, it is an agent or patient’s responsibility to know insurance coverage for services, as some services and general medical coverage may be provided by two separate plans. I understand that it is my responsibility to pay any co‐pay, deductible, co‐insurance, or any other balance not paid for by insurance or third‐party payor within a reasonable time not to exceed 30 days. If you are considered the guarantor, you will provide your name, Date of Birth, and Social Security Number to satisfy requirements to bill insurance companies. Our office staff is happy to help answer questions and help with this process.

*Initials

Financial Agreement –The signatory agrees, whether the signatory signs as an agent or as a patient, that in consideration of services to be rendered to the patient, the signatory obligates them to pay charges for services received in accordance with regular rates and terms of Elite DNA Therapy Services, LLC. We reserve the right to assign unpaid bills to a collection agency. Should your account be referred to an attorney for collections, the signatory should pay reasonable attorney’s fees and collection expense. If you have any questions about this agreement, please feel free to ask for clarification.

The signatory certifies that he or she has read, understands, and accepts these terms and conditions of this document and is either the patient or is duly authorized by the patient as the patient’s general agent to execute the above agreement and may receive a copy upon request.

*Printed Name of Patient or Guardian

Relationship to Patient

*Signature of Patient or Guardian

*Date

You have the right to request copies of all signed documents.

Elite DNA Therapy Services, LLC
Authorization and Consent for Other Individuals to Accompany Minor

*Initials

I understand and agree that I am not required to authorize any other individual to present or accompany minor named above to Elite DNA Therapy Services, LLC. However, by completing this authorization, I am voluntarily giving consent for the individual(s) named below to bring minor named above to Elite DNA Therapy Services, LLC for to receive services described in the General Consent for Treatment.

*Initials

I likewise, understand and agree that my authorization and consent does not replace my responsibility for cooperation and involvement in the treatment of minor named above as outlined and agreed to by signing the General Consent for Treatment.

*Initials

I fully understand for psychiatric appointments no medication changes will be completed without custodial written approval. I have been informed that professional judgement Elite DNA Therapy Services, LLC will be exercised regarding any changes in treatment when minor named above is accompanied by an authorized alternative individual below to whom I give my authorization and consent to accompany minor named above.

*Initials

Furthermore, I hereby certify that the alternative individual(s) named below may lawfully be described as one of the statutorily allowable individuals who may provide consent for medical care of a minor under Fla. Stat. §743.0645, such that each person is either a “health care surrogate”, “stepparent”, “grandparent”, “adult sibling”, or “adult aunt or uncle” of minor. Individuals with any relationship to minor other than those described in the preceding sentence have my explicit consent to accompany minor named above.

*Initials

I understand that I may revoke this authorization and consent of individual(s) listed below at any time.

I hereby authorize and consent that the following individual(s) may accompany my minor named above to appointments
at Elite DNA Therapy Services, LLC (Use back of page if more persons are added.):

*Name

Address

Date of Birth

Relationship to Patient:

*Name

Address

Date of Birth

Relationship to Patient:

Printed Name of First Patient or Guardian

Relationship to Patient

Signature of First Patient or Guardian

*Date

Printed Name of First Patient or Guardian

Relationship to Patient

Signature of Second Patient or Guardian

*Date

Elite DNA Therapy Services, LLC
Custody Status Agreement

*Name

*Date of Birth

Check Here if there has NEVER BEEN A DISPUTE REGARDING CUSTODY OF MINOR. Sign and date below.

*Initials

I understand and agree if any information provided to Elite DNA Therapy Services, LLC has been misrepresented or if important changes of information are not timely communicated to Elite DNA Therapy Services, LLC, such misrepresentations or failures to disclose may result in suspension or termination of services.

*Initials

By completing this Agreement, I certify that there is a final decision or an ongoing custody dispute
and/or custody consideration and a court order regarding custody has not been issued. Regardless of status, as a legal guardian of minor named above, I understand that it is my responsibility to inform all legal guardians that minor is
receiving services at Elite DNA Therapy Services, LLC.

*Initials

I understand and agree to provide copies of official legal documentation to Elite DNA Therapy Services,
LLC as soon as possible and / or if there are changes or decisions made regarding custody considerations.

*Initials

I understand and agree that if lack of cooperation or participation of minor’s legal guardians or if custody issues or disputes are hindering or otherwise preventing appropriate treatment of minor; treatment and services may be suspended or terminated by our sole discretion. Elite DNA Therapy Services, LLC will not become involved in disputes between guardians (legally appointed or not) and has the right to suspend or terminate treatments or services if disputes become disruptive or adversarial in the best interests of our staff, patients, and visitors.

*Initials

I understand and agree that it shall be within the medical and professional judgement and discretion of Elite DNA Therapy Services, LLC to provide appropriate services. I understand and agree it is my responsibility to put the emotional and mental health needs of the minor before any custody or legal complications. I agree I will fully
cooperate and participate in the minor’s treatment, and likewise will encourage all legal guardians to cooperate and
participate to the extent it is appropriate and legally permissible to do so.

*Initials

I understand that all legal guardians have rights to obtain patient medical records upon request. However, if there are any conflicts, disputes, legal ramifications, or authorization concerns, Elite DNA Therapy Services, LLC, using their medical and professional judgement may withhold release of such records on behalf of minor. In such a situation, Elite DNA Therapy Services, LLC is asserting the psychotherapist-patient privilege on behalf of minor pursuant
to Florida Statutes § 90.503(3).

I hereby authorize and consent that the following individual(s) may accompany my minor named above to appointments
at Elite DNA Therapy Services, LLC (Use back of page if more persons are added.):

Printed Name of First Patient or Guardian

Relationship to Patient

Signature of First Patient or Guardian

*Date

Printed Name of First Patient or Guardian

Relationship to Patient

Signature of Second Patient or Guardian

*Date

Patient’s Bill of Rights and Responsibilities

Section 381.026, Florida Statutes

A patient has the right to:

Be treated with courtesy and respect, with an appreciation of his or her dignity, and with the protection of privacy. Receive a prompt and reasonable response to questions and requests.

Know who is providing medical services and is responsible for his or her care.

Know what patient support services are available, including if an interpreter is available if the patient does not speak English.

Know what rules and regulations apply to his or her conduct.

Be given by the health care provider information such as diagnosis, planned course of treatment, alternatives, risks, and prognosis.

Refuse any treatment, except as otherwise provided by law.

Be given full information and necessary counseling on the availability of known financial resources for care.

Know whether the health care provider or facility accepts the Medicare assignment rate if the patient is covered by Medicare.

Receive prior to treatment, a reasonable estimate of charges for medical care.

Receive a copy of an understandable itemized bill and, if requested, to have the charges explained.

Receive medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment.

Receive treatment for any emergency medical condition that will deteriorate from failure to provide treatment.

Know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such research.

Express complaints regarding any violation of his or her rights.

A patient is responsible for:

Giving the health care provider accurate information about present complaints, past illnesses, hospitalizations, medications, and any other information about his or her health.

Reporting unexpected changes in his or her condition to the health care provider.

Reporting to the health care provider whether he or she understands a planned course of action and what is expected of him or her.

Following the treatment plan recommended by the health care provider.

Keeping appointments and, when unable to do so, notifying the health care provider or facility.

His or her actions if treatment is refused or if the patient does not follow the health care provider’s instructions.

Making sure financial responsibilities are carried out.

Following health care facility conduct rules and regulations.

Agency for Health Care Administration – Visit us at www.FloridaHealthFinder.gov

If you have questions or concerns, please contact our Privacy Officer. Phone: 239.223.2751 Emal: Privacy@EliteDNATherapy.com Hotline: 888.453.3114

I have read my Bill of Rights and Responsibilities

Elite DNA Therapy Services, LLC
Notice of Privacy Practices

Purpose:

This notice describes how your medical information may be used and disclosed and how you can get access to this information. Please review this notice carefully.

Our Commitment to Your Privacy

Our practice is dedicated to maintaining the privacy of your Individually Identifiable Health Information (IIHI) or Protected Health Information (PHI). This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected Health Information (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services. At Elite DNA Therapy Services, the privacy of your medical information is important to us. We understand that your medical information is personal, and we are committed to protecting it. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. Our practice will also post a copy in our office in a visible location always.

Understanding Your Health Record/Information

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

Basis for planning your care and treatment
Means of communication among the many health professionals who contribute to your care
Legal document describing the care you received
Means by which you or a third-party payer can verify that services billed were actually provided
A tool in educating health professionals
A source of data for medical research
A source of information for public health officials charged with improving the health of the nation
A source of data for facility planning and marketing
A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve
Understanding what is in your record and how your health information is used helps you to:

Ensure its accuracy
Better understand who, what, when, where, and why others may access your health information
Make more informed decisions when authorizing disclosure to others
Your Health Information Rights

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522
Obtain a paper copy of the notice of information practices upon request
Inspect and obtain a copy of your health record as provided for in 45 CFR 164.524
Request to amend your health record as provided in 45 CFR 164.528
Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528
Request communications of your health information by alternative means or at alternative locations
Revoke your authorization to use or disclose health information except to the extent that action has already been taken Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
Right to A Copy of Your Medical Records

This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. To inspect and copy medical information that may be used to make decisions about you, you must contact the office to obtain an Authorization Form. Once you have received this form, please fill it out thoroughly and send the form back to the office. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewed. In some circumstances, you may have a right to have this decision reviewed.

Right to Request Restrictions

You may request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your physician does 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. Please discuss any restriction you wish to request with your physician. You may request a restriction by contacting the office for a “Request of Restrictions Form”. This form must be submitted to our office.

Right to Amend

This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for 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. Please contact our Privacy Officer to obtain the “Health Record Amendment Form”. This form must be submitted to our office.

Right to Receive Certain Accounting Disclosures

This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. Please contact our Privacy Officer to obtain the “Request for Accounting Disclosures Form”. This form must be submitted to our office.

Right to Obtain A Paper Copy

You are entitled to receive a paper copy of our notice of privacy practices. To obtain a paper copy of this notice, please contact the Office.

Our Responsibilities

Elite DNA Therapy Services, LLC is required to:

Maintain the privacy of your health information
Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
Abide by the terms of this notice
Notify you if we are unable to agree to a requested restriction
Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us.

We will not use or disclose your health information without your authorization, except as described in this notice.

How We May Use and Disclose Your Information Treatment

For example: Information obtained by a nurse, physician, or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you’re discharged from this hospital.

Payment

For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

Healthcare Operations

For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used to continually improve the quality and effectiveness of the healthcare and service we provide.

Business Associates

There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Appointment Reminders

We may contact you by phone or leave a message on your home, work or cell phone as a reminder that you have an appointment scheduled for medical care at the office. Please notify us if you do not wish to be contacted for appointment reminders.

Notification

We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.

Communication with Family Members

Health professionals, using their best judgment, may disclose to a family member, other relative, close friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

Research

We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Disclosures Required by Law

We may use or disclose your protected health information to the extent that the use or disclosure is required by federal, state, or local law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

Military and National Security

When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Workers’ Compensation/Health Oversight Activities

Your Protected Health Information may be disclosed by us as authorized to comply with Workers’ Compensation laws and other similar legally-established programs.

We may disclose your Protected Health Information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

Lawsuits and Disputes

If you are involved in a lawsuit or a dispute, we may disclose your medical information in response to a court or administrative order. We may also disclose your medical information in response to a subpoena.

Coroners, Medical Examiners and Funeral Directors

We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death.

Other Uses and Disclosures of Health Information

We will not use or disclose your Protected Health Information for any purpose other than those identified in the previous sections without your specific, written Authorization. If you give us Authorization to use or disclose health information about you, you may revoke that Authorization in writing at any time. If you revoke the Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission. We cannot release you’re your Psychotherapy Notes without a special signed, written authorization (different than the Authorization mentioned above) from you. To disclose these types of records for purposes of treatment, payment or health care operations, we will have to have a special written authorization that complies with the law.

Food and Drug Administration (FDA)

We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Correctional Institution

Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Complaints (Anonymous Hotline Number 888.453.3114)

There will be no retaliation for filing a complaint.

If have questions and would like additional information, you may contact our Privacy Officer at 239.223.2751

If you believe your privacy rights have been violated, you can file a complaint with our Privacy Officer at 239.223.2751 or privacy@elitednatherapy.com.

OR with the Secretary of Health and Human Services by using the information below:

Timothy Noonan, Regional Manager

Office for Civil Rights

U.S. Department of Health and Human Services

Sam Nunn Atlanta Federal Center, Suite 16T70

61 Forsyth Street, S.W.

Atlanta, GA 30303-8909

Customer Response Center: (800) 368-1019

Fax: (202) 619-3818

TDD :(800) 537-7697

Email: ocrmail@hhs.gov

This revised notice was published and becomes effective on January 30, 2018.

I have read Elite DNA Therapy Services' Notice of Privacy Practices

Jacksonville Child Intake Form

Elite DNA Therapy Services, LLCGeneral Consent for Treatment

Patient’s Bill of Rights and Responsibilities

Elite DNA Therapy Services, LLCNotice of Privacy Practices

Elite DNA Therapy Services, LLC
General Consent for Treatment

Elite DNA Therapy Services, LLC
Notice of Privacy Practices