Cadet Consent For Medical Treatment (Page 6 of 6) in pdf

VALLEY FORGE MILITARY ACADEMY & COLLEGE

NOTICE OF PRIVACY PRACTICES

CADET NAME ______________________________

Understanding Your Health Information: Each time you visit a hospital, clinic, physician, or other health care provider, a record of your visit is made. Typically, this health record

contains your medical history, symptoms, examination and test results, diagnosis, treatment, care plan, insurance, and billing information. This health information is considered private

and protected. This health information, often referred to as your health record, serves as a basis for planning your care and treatment, and is a vital means of communication among the

many health professionals who contribute to your health care. Your health information is also used by insurance companies and other third-party payers to verify the appropriateness of

billed services. We are required by law to: Maintain the privacy of your health information. Provide you with an additional current copy of our notice upon request. Abide by the terms

of our current Notice.

How We Disclose Medical Information about you: For Treatment: We may provide medical information about you to doctors, nurses, the athletic trainers or Cadet Counseling

Center counselors involved in your care. We also may disclose information about you to people outside the health center who may be involved in your medical care. This includes but

is not limited to physicians, family members, emergency contacts, tactical officers, nurses, technicians, medical students, or others that may provide part of your care. For Payment: We

may discuss your health information with your insurer, parent/guardian, or specified emergency contact to verify your eligibility for benefits, obtain prior authorization, and to bill for the

treatment and services rendered. For Health Care Operations: We may disclose and use your medical information for practice functions such as reviewing the quality of care

delivered, education, and planning. Appointment Reminder and Follow Up: We may use your information to contact you as a reminder that you have an appointment with us or a

consultant. Other Health Care Providers: We may disclose your information to other health care providers when it is necessary for them to treat you, receive payment for services

rendered, or conduct certain health care operations. This includes, but is not limited to athletic training staff and Cadet Counseling Center staff. To Avert a Serious Threat to Health

or Safety: We may disclose medical information about you when necessary to prevent a serious threat to your health and safety or that of another person or the public. Public Health

Risk or Activities: We may disclose medical information about you for Public Health Activities. This may include the prevention or control of a disease or illness, report abuse or

neglect, to notify people of recalls and to report reactions to medications or vaccinations. Health Oversight Activities: We may disclose your information to a health oversight agency

that is responsible for monitoring the health care system, government programs, and compliance with civil rights laws. Legal Proceedings and Law Enforcement: We will disclose

medical information about you when required to do so by federal, state, or local law. We may disclose your information in response to a court order, subpoena, or other lawful process.

Your Rights Regarding Your Health Information: Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions

about your care. You must submit a written request to the Health Center Director, 1001 Eagle Road, Wayne, Pennsylvania, 19087. We may charge a fee for the copying, mailing or use

of other supplies associated with your request. We may deny your request to inspect and copy in certain limited circumstances. You may request that the denial be reviewed. Another

licensed health care professional chosen by the Health Center will review your request and denial. We will comply with the outcome of the review. Right to Amend: You have the

right to request that we amend the health information we keep about you in your medical and billing records. Request should be made in writing to the Director of the Health Center.

We may deny your request if we believe the information you wish to amend to be accurate, current and complete, if the record was not created by the Health Center or if other special

circumstances apply. Right to Accounting of Disclosure: You have the right to request an accounting of disclosure. We are not required to give you an accounting of information we

have used or disclosed for treatment, payment, health care operations, or information you authorized us to disclose. Requests should be made in writing to the Health Center. Right to

Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations.

You also have the right to request we limit the medical information we disclose to someone involved in your care or the payment of your care. We are not required to agree with your

request. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment. Request should be made in writing to the Health Center

Director. Right to Request Confidential Communication: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.

Request should be made in writing to the Health Center Director. Right to Revoke Your Written Permission (Authorization): You may change your mind about your authorization

or any written permission regarding your Highly Confidential Information by giving or sending a written "revocation statement" to the Privacy Office at the address below. The

revocation will not apply to the extent that we have already taken action where we relied on your permission.

Changes to This Notice: We reserve the right to revise this notice. We reserve the right to make the changed notice effective for the information we already have as well as any

information we may receive in the future. Complaint: If you believe your privacy rights have been violated, you may file a complaint with the Health Center Director. There will be

no retaliation for filing a complaint. Other Use of Medical Information: Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will

be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If

you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable

to take back any disclosures we have already made with your permission, and that we are required to retain a record of the care that we provided to you.

AUTHORIZATION FOR USE/DISCLOSURE OF PROTECTED HEALTH INFORMATION

The Valley Forge Military Academy & College is committed to protecting each Cadet’s privacy, in regard to certain health information as mandated by state and federal laws

and regulations, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and will generally not release a Cadet’s Protected Health Information without first

obtaining the Cadet’s authorization. “Protected Health Information” (PHI) includes information that has been created or received by Valley Forge Military Academy & College

regarding your health. It includes your medical records, current medication, treatment, and personal information such as your name and social security number.

Authorization for Use/Disclosure of Information: I voluntarily authorize and direct the Office of Cadet Health Services to use or disclose my Protected Health Information during the

term of this authorization to my parents and/or legal guardian, the Tactical Officer assigned to my Unit, to faculty, the administration, and other medical professionals. Purpose: This

Authorization is made at my request to assist in my ongoing medical care and to best facilitate my educational experience at the Valley Forge Military Academy & College.

Information to be Disclosed: This authorization permits the Valley Forge Military Academy & College to disclose the following medical records/information: Those medical records

and information concerning any prescribed medication that I am taking while enrolled at the Valley Forge Military Academy & College, as directed by my personal physician. Term:

This Authorization will remain in effect from the date of this Authorization until the date I am discharged from the Valley Forge Military Academy & College. Right to Revoke: I

understand that I may revoke this Authorization for any reason and that such revocation will not affect the commencement, continuation, or quality of my treatment as facilitated by the

Office of Cadet Health Services or my educational opportunities at the Valley Forge Military Academy & College.

___________________________________

________________________________

PARENT OR GUARDIAN’S SIGNATURE

CADET SIGNATURE (if age 18 or older)

__________________________________________

______________________________________

DATE