Beaver Medical Group - Appointment Request

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Copyright
Beaver Medical Group.
All rights reserved.

Revised
February 2004

Appointment Request, Confirmation or Cancellation
To request or cancel an appointment, please provide the following information. A Beaver Medical Group Representative will contact you within one business day.

Please choose an option:
Patient Last Name	Patient First Name
Patient Date of Birth: (MM DD YYYY)
Patient Address	City	State	ZipCode
Doctor Name:
Would your prefer to be contacted in the: No Preference Afternoon Morning
Phone number where you will be available (cell, work, home, etc.):
Reason for your visit: Your e-mail address

For Cancellations only:
Please fill out the above and the following only if you are cancelling an appointment at least 48 hours in advance. If your appointment is scheduled within 24 hours, please call 909-335-4105, then press "1" and leave a message.

Patient Name: If different than above

Date of Appt.

Time of Appt.

Doctor/ Provider:

By clicking on the submit button, I acknowledge that
I have been presented with the Notice of Privacy Practices.

NOTICE OF PRIVACY PRACTICES
Effective 4/14/2003
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.
If you have any questions about this notice, please contact the Corporate Compliance Office at (909) 793-3311.
WHO WILL FOLLOW THIS NOTICE:
This notice describes our privacy practices and that of:
ï	Any health care professional authorized to enter information into your medical chart.
ï	All employees, staff and volunteers.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
We understand that medical information about you and your health is personal.  We are committed to protecting medical information about you.  We create a record of the care and services you receive at the clinic.  We need this record to provide you with quality care and to comply with certain legal requirements.  This notice applies to all of the records of your care generated by our practice, whether made by personnel or your  doctor.
This notice will tell you about the ways in which we may use and disclose medical information about you.  We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.
We are required by law to:
ï	make sure that medical information that identifies you (identifiable health information) is kept private;
ï	give you this notice of our legal duties and privacy practices with respect to medical information about you; and
ï	follow the terms of the notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU:
The following categories describe different ways that we use and disclose identifiable health information.  For each category of uses or disclosures we will explain what we mean and try to give some examples.  Not every use or disclosure in a category will be listed.  However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
ï	FOR TREATMENT  We may use your identifiable health information to treat you.  For example, we may ask you to undergo laboratory tests (such as blood or urine tests), and we may use the results to help reach a diagnosis.  We might use your identifiable health information in order to write a prescription for you, or we might disclose your identifiable health information to a pharmacy when we call and order a prescription for you.  Many of the people who work for our practice - including our doctors and nurses - may use or disclose you identifiable health information in order to treat you or to assist others in your treatment.  Additionally, we may disclose your identifiable health information to others who may assist in your care, such as your spouse, children or parents.
ï	PAYMENT Our practice may use and disclose your identifiable health information in order to bill and collect payment for the services and items you may receive from us.  For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment.
ï	HEALTH CARE OPERATIONS Our practice may use and disclose your identifiable health information to operate our business.  For example, our practice may use your health information to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice.
ï	APPOINTMENT REMINDERS Our practice may use and disclose your identifiable health information to contact you and remind you of an appointment.
ï	TREATMENT OPTIONS We may use and disclose your identifiable health information to inform you of potential treatment options or alternatives.
ï	HEALTH-RELATED BENEFITS AND SERVICES Our practice may use and disclose your identifiable health information to inform you of health-related benefits or services that may be of interest to you.
ï	RELEASE OF INFORMATION TO FAMILY/FRIENDS Our practice may release your identifiable health information to a friend or family member who is helping you pay for your health care, or who assists in taking care of you.
ï	DISCLOSURES REQUIRED BY LAW Our practice will use and disclose your identifiable health information when we are required to do so by federal, state or local law.
SPECIAL SITUATIONS
ï	PUBLIC HEALTH RISKS As required by law, we may disclose your identifiable health information to public health or legal authority charged with preventing or controlling disease, injury, or disability.
ï	HEALTH OVERSIGHT ACTIVITIES We may disclose identifiable health information to a health oversight agency for activities authorized by law.  These oversight activities may include audits, investigations, inspections, and licensure.
ï	LAWSUITS AND SIMILAR PROCEEDINGS If you are involved in a lawsuit or a dispute, we may disclose identifiable health information in response to a court or administrative order.  We may also disclose identifiable health  information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
ï	LAW ENFORCEMENT We may disclose identifiable health information for law enforcement purposes as required by law or in response to a valid subpoena.
ï	CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS We may release identifiable health information to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death.  We may also release identifiable health information about patients of our practice to funeral directors as necessary to carry out their duties.
ï	ORGAN AND TISSUE DONATION Consistent with applicable law, we may disclose identifiable health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation or transplant.
ï	RESEARCH We may disclose identifiable health  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.
ï	MILITARY AND VETERANS Our practice may disclose your identifiable health information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities.
ï	WORKERSí COMPENSATION We may release identifiable health information for workersí compensation or similar programs.
ï	NATIONAL SECURITY Our practice may disclose your identifiable health information to federal officials for intelligence and national security activities authorized by law.  We also may disclose your identifiable health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct special investigations.
ï	INMATES Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof identifiable health information necessary for your health and the health and safety of others.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
You have the following rights regarding the identifiable health information that we maintain about you:
1.  Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  For example, you can ask that we only contact you at work or by mail.  To request confidential communication, you must make your request in writing to the Patient Liaison.  We will not ask you the reason for your request.  We will accommodate all reasonable requests.  Your request must specify how or where you wish to be contacted.
2.  Requesting Restrictions.  You have the right to request a restriction or limitation on the identifiable health information we use or disclose about you for treatment, payment or health care operations.  You also have the right to request a limit on the identifiable health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.  We are not required to agree to your request.  If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.  To request restriction, you must make your request in writing to the Director of Medical Records.  
Your request must describe in a clear and concise fashion: (a) the information you wish restricted; (b) whether you are requesting to limit our practiceís use, disclosure or both; and (c) to whom you want the limits to apply.
3.  Inspection and Copies.  You have the right to inspect and obtain a copy of the identifiable health information that may be used to make decisions about you, including medical records and billing records, but not including psychotherapy notes.  You must submit your request in writing to the Director of Medical Records in order to inspect and/or obtain a copy of your identifiable health information.  Our practice may charge a fee for the costs of copying, mailing, or other supplies associated with your request.  Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial.  Reviews will be conducted by another licensed health care professional chosen by us.
4.  Amendment.  If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept by or for our practice.  To request an amendment, your request must be made in writing and submitted to the Director of Medical Records.  You must provide us with the reason that supports your request.  We will deny your request if it is not in writing or does not include a reason to support the request.  In addition we may deny your request if you ask us to amend information that is: (a) accurate and complete; (b) not part of the identifiable health information kept by or for the practice; (c) not part of the information which you would be permitted to inspect and copy; or (d) not created by our practice, unless the person or entity that created the information is no longer available to make the amendment.
5.  Accounting of Disclosure.  You have the right to request an ìaccounting of disclosuresî.  This is a list of disclosures we made of identifiable health  information about you.  To request this list of ìaccounting of disclosuresî, you must submit your request in writing to the Director of Medical Records.  Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003.  The first list you request within a 12 month period is free of charge, but our practice may charge you for additional lists within the same 12 month period.  Our practice will notify you of the costs involved with additional request, and you may withdraw your request before you incur any costs.
6.  Right to a Paper Copy of This Notice.   You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time.  To obtain a paper copy of this notice, contact the Corporate Compliance Office at (909) 793-3311.
CHANGES TO THIS NOTICE 
We reserve the right to revise or amend our notice of privacy practices.  Any revision or amendment to this notice will be effective for all of your records our practice has created or maintained in the past, and for any of your records we may create or maintain in the future.  Our practice will post a copy of our current notice in our offices in a prominent location, and you may request a copy of our most current notice at any time.
COMPLAINTS
If you believe your rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services.  To file a complaint with our practice, contact the Corporate Compliance Office at (909) 793-3311.  All complaints must be submitted in writing.  You will not be penalized for filing a complaint.
OTHER USES 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 identifiable health information, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose identifiable health information  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 our records of the care that we provided to you.
ADDRESS
Please send all correspondence to:
Beaver Medical Group, L.P.
P.O. Box 3001
Redlands, CA 92373-9896

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