THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

This notice describes OnCall Healthcare's privacy practices. OnCall Healthcare and all of its entities, sites, providers, and locations follow the terms of this notice. In addition, these entities, sites, providers, and locations may share health information with each other for treatment, payment, or health care operations purposes described in this notice.

Our Pledge Regarding Health Information:

We understand that information about you, your health, and your health care is personal. We are committed to protecting your personal health information (PHI).

We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all records of your care generated by this health care practice, whether made by your personal provider or others working in this office. This notice will tell you about the ways in which we may use and disclose your PHI. We also describe your rights to the PHI we keep about you, and describe certain obligations we have regarding the use and disclosure of your PHI.

We are required by law to:

• Make sure that health information that identifies you is kept private
• Give you this notice of our legal duties and privacy practices with respect to PHI
• Follow the terms of this notice that is currently in effect

HOW WE MAY USE & DISCLOSE YOUR PHI: The following categories describe different ways that we use and disclose health information. We also provide some examples. All the ways we are permitted to use and disclose information will fall within one of the categories. However, the list of examples is not exhaustive and so not every use or disclosure possible in a category is listed.

FOR TREATMENT: We may use health information about you to provide you with health care treatment or services. We may disclose health information about you to physicians, nurses, technicians, health students, or other personnel who are involved in taking care of you. They may work at our offices; at the hospital if you are hospitalized under our supervision; or at another physician’s office, lab, pharmacy, or other health care provider where we may have referred you for x-rays, laboratory tests, prescriptions, or other treatment purposes. For example, a physician treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the physician may need to tell the dietitian at the hospital if you have diabetes so that they can arrange for appropriate meals. We may also disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

FOR PAYMENT: We may use and disclose information about treatment and services we provided to you for billing purposes. These fees may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about your office visit so that your health plan will pay us or reimburse you for the visit. We may also tell your health plan about a treatment before you receive it so that we can obtain prior approval or determine if you plan will cover treatment.

FOR HEALTH CARE OPERATIONS: We may disclose health information about you for the operation of our health care practice. These uses and disclosures are necessary to run our practice and to make sure that all our patients receive quality care. For example, we may use health information in a general review of our treatments and services or, more specifically, to evaluate the performance of our staff in caring for you. We may also combine the health information of many patients to decide what improvement we could make, what additional services we should offer, what services are not needed, or whether certain new treatments are effective. We may remove information that identifies you from this set of health information so others may use it to study health care delivery without learning who our specific patients are.

APPOINTMENT REMINDERS: We may use and disclose health information to contact you as a reminder that you have an appointment or that you missed an appointment and should contact us to reschedule. Please let us know if you do not wish to have us contact you for this purpose or if you wish us to use a different address to contact you for this purpose.

HEALTH-RELATED SERVICES & TREATMENT ALTERNATIVES: We may use and disclose health information to tell you about health-related services or recommend possible treatment options or alternatives that may be of interest to you. Please let us know if you do not wish us to send you this information or if you wish us to use a different address to send this information to you.

RESEARCH: Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received a medication to those who received another medication for the same condition. The Quality Assurance Committee of the Board of Directors must approve all research projects. This committee evaluates all potential projects and selects those that will be of direct or indirect benefit to our patients and/or community. Their review process also evaluates a proposed research project’s use of health information, trying to balance the needs of the research community with patients’ need for privacy. We will obtain your written authorization to use your PHI for research purposes except when our Quality Assurance Committee has determined that:

The use or disclosure involves no more than a minimal risk to your privacy based on the following:

• An adequate plan to protect the identifying information from improper use and disclosure;
• An adequate plan to destroy the identifying information at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and
• Adequate written assurances that the PHI will not be reused or disclosed to any other person or entity (except as required by law for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted).

The research should not practically be conducted without the waiver; and the research could not practically be conducted without access to and use of the PHI.

Before we use or disclose health information for research, the project will have been approved through our approval process. However, we may disclose health information about you to people preparing to conduct a research project. For example, we may help potential researchers look for patient with specific health needs, as long as the health information they review does not leave our facility.

ORGAN & TISSUE DONATION:  If you are an organ donor, we may release health information to an organ donation bank or to organizations that handle organ procurement or organ, eye, or tissue transplantation, as necessary to facilitate organ or tissue donation and transplantation.

AS REQUIRED BY LAW: We will disclose health information about you when required to do so by federal, state, or local law.

TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY: We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

MILITARY & VETERANS: If you are a member of the armed forces or separated or discharged from military services, we may release health information about you as required by military command authorities or the Department of Veterans’ Affairs we may be applicable. We may also release health information about foreign military personnel to the appropriate foreign military authorities.

WORKERS' COMPENSATION: We may release health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

PUBLIC HEALTH RISKS: We may disclose health information about you for public health activities. These activities generally include the following:

• The prevention or control of disease, injury, or disability
• The reporting of births and deaths
• The reporting of child abuse or neglect
• The reporting of reaction to medications or problems with products
• The notification of people about recalls of products they may be using
• The notification of a person or organization required to receive information on Food and Drug Administration regulated products
• The notification of a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
• The notification of the appropriate government authority, if we believe a patient has been the victim of abuse, neglect, or domestic violence (we will only make this disclosure if you agree or when required or authorized by law)

HEALTH OVERSIGHT ACTIVITIES: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

LAWSUITS & DISPUTES: If you are involved in a lawsuit or a dispute, we may disclose your health information in response to a court or administrative order. We may also disclose health information about you 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 toll you about the request or to obtain an order protecting the information requested.

LAW ENFORCEMENT: We may release health information if asked to do so by a law enforcement official:

• In reporting certain injuries, as required by law: gunshot wounds, burns, dog bites, and injuries to perpetrators of crime
• In response to a court order, subpoena, warrant, summons, or similar process
• To identify or locate a suspect, fugitive, material witness, or missing person (name and address, date of birth or place of birth, social security number, blood type or Rh factor, type of injury, date and time of treatment and/or death, if applicable, and a description of distinguishing physical characteristics)
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement
• About a death we believe may be the result of criminal conduct
• About criminal conduct at our facility
• In emergency circumstances to report a crime; the location of a crime or victims; or the identity, description, or location of a person who committed a crime

CORONERS, HEALTH EXAMINERS & FUNERAL DIRECTORS: We may release health information to a coroner or health examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients to funeral directors as necessary to carry out their duties.

NATIONAL SECURITY & INTELLIGENCE ACTIVITIES: We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

PROTECTIVE SERVICES FOR THE PRESIDENT & OTHERS: We may disclose health information about you to authorized federal officials so they may conduct special investigation or provide protection to the President, other authorized persons, or foreign heads of state.

INMATES: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

You have the following rights regarding health information we maintain about you:

RIGHT TO INSPECT & COPY: You have the right to inspect and copy health information that may be used to make decision about your car. Usually, this includes health and billing records. To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing. Please send request to healthcare@oncallhc.com, attention Records. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies and services associated with your request.

RIGHT TO AMEND: If you believe 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 we keep the information. To request an amendment, your request must be made in writing. Please send your request to healthcare@oncallhc.com, attention Records and provide your reason for the amendment.

We may deny your request for an amendment if it is not in writing or does not include a reason for the request. In addition, we may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment
• Is not part of the health information kept by or for our practice
• Is not part of the information that you would be permitted to inspect and copy
• Is accurate and complete

Any amendment we make to your health information will be disclosed to those with whom we disclose information as previously specified.

RIGHT TO AN ACCOUNTING DISCLOSURE: You have the right to request a list of the disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and health care operations, as previously described. Please send your request to healthcare@oncallhc.com, attention Records.

RIGHT TO REQUEST RESTRICTIONS: You have the right to request a restriction or limitation on the 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 health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we withhold your information from a specified nurse or that we not disclose information to your spouse about a surgery you had.

We are not required to agree to your request for restrictions if it is not feasible for us to ensure our compliance or believe it will negatively affect the care we provide you.

If we do agree, we will comply with your request, unless the information is needed to provide you emergency treatment. To request a restriction, you must submit your request in writing. Please send your request to healthcare@oncallhc.com, attention Records. If you request, you must tell us what information you want to limit and to whom you want the limits to apply.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS: You have the right to request that we communicate with you about health 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 a post office box. To request confidential communications, you must make your request in writing. Please send your request to healthcare@oncallhc.com, attention Records. 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 us to contact you.

RIGHT TO A PAPER COPY OF THIS NOTICE: You have the right to obtain a paper copy of this notice at any time. To obtain a copy, please send your request to healthcare@oncallhc.com, attention Records.

RIGHT TO COMPLAIN: If you have any questions about this Notice or would like to file a complaint about our privacy practices, please direct your comments to healthcare@oncallhc.com. You may also file a complaint with the Secretary of the Department of Health and Human Services. You will not be retaliated against or penalized for filing a complaint.

CHANGES TO THIS NOTICE: We reserve the right to change the terms of this Notice at any time. We reserve the right to make the new Notice provisions effective for all health information we currently maintain, as well as any health information we receive in the future. If we make material or important changes to our privacy practices, we will promptly revise our Notice. We will post a copy of the current Notice on our OnCall Healthcare e-clinic check-in page as well as in our office. Each version of the Notice will have an effective date listed on the first page. Updates to this Notice are also available at our web site, www.oncallhc.com.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

OnCall Healthcare LLC is committed to protecting your privacy and ensuring that your health information is used and disclosed appropriately. This Notice of Privacy Practices identifies all potential uses and disclosures of your health information by our organization and outlines your rights with regard to your health information.

BY USING OR OTHERWISE ACCESSING THE SERVICES, AND/OR BY REGISTERING WITH ONCALL HEALTHCARE, YOU AGREE TO ONCALL HEALTHCARE'S INFORMED CONSENT FOR TREATMENT AND HEREBY AUTHORIZE THE PROFESSIONAL STAFF AT ONCALL HEALTHCARE TO ADMINISTER TREATMENT FOR THE PURPOSE OF MEDICAL CARE AS NEEDED.

The Patient You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

The Provider Providers are Board Certified Nurse Practitioners (NP). NP's have additional advanced training in nursing. During your sessions, providers shall go through your health concerns and identify issues you may or may not have. Providers shall review issues and identify whether or not they are capable of addressing your issues.

Session Length There is no specific determination on how many sessions are needed by a client/patient as this may depend on the progress of said client/patient and this can be discussed with your provider.

Relationship The required relationship that a client/patient should have with his/her provider is strictly professional. Any other relationship, such as business or personal relationships that a client/patient may have with a provider may prevent or undermine the effectiveness of the treatment.

Confidentiality Visits between the provider and the client/patient are strictly confidential. Any notes taken by the providers, audio recordings, video recordings during your visits shall be kept confidential and secure by the providers at all times and shall not be disclosed without prior written consent by the client/patient, with exception to certain limitations by law such as:

• Abuse to a child, disabled, elderly, other people;
• Criminal Acts;
• Sexual Abuse;
• Acts which may involve the transmission of HIV/AIDS;
• Any other instance where the provider has a duty or he or she has a firm belief that there is a necessity to disclose. In case you have any questions regarding confidentiality, please discuss this with your provider.

Risks You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

Court Proceedings In case of a court proceeding involving the client/patient, it is agreed that the providers cannot testify, such as but not limited to, custody proceedings, divorce proceedings, injuries, or any other lawsuits that shall result in the disclosure of the records of the provider about his/her client/patient.

Questions For questions or concerns, please email us at healthcare@oncallhc.com.

This consent can be revoked orally or in writing prior to or during the treatment period. No guarantee or assurance has been made to me as to the results that may be obtained.

All healthcare providers are legally required to report incidences of communicable diseases to the Department of Public Health. If, during the course of treatment, it is determined by your healthcare provider that you have acquired a communicable disease, this information will be reported to the Department of Public Health. This report will be made to individuals who are required by law to be notified.

I voluntarily request a physician, and/or mid level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I have been informed of the nature and purpose of treatment, common side effects thereof, alternative treatment modalities, approximate length of care, and that consent can be revoked orally or in writing prior to or during the treatment period.

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Telemedicine involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include but may not be limited to, primary care practitioners, specialists, and/or sub-specialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records
• Medical images
• Live two-way audio and video
• Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

EXPECTED BENEFITS:

• Improved access to medical care
• More efficient medical evaluation and management
• Obtaining expertise of a distant specialist

POSSIBLE RISKS:

• In rare cases, information transmitted may not be sufficient to allow for appropriate medical decision making by the physician and consultant(s).
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

​BY USING OR OTHERWISE ACCESSING THE SERVICES, AND/OR BY REGISTERING WITH US, YOU AGREE TO ONCALL HEALTHCARE'S INFORMED CONSENT FOR TELEMEDICINE AND UNDERSTAND THE FOLLOWING:

• I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
• I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
• I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
• I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My healthcare provider has explained the alternatives to my satisfaction.
• I understand that telemedicine may involve electronic communication of my personal medical information to other healthcare providers who may be located in other areas, including out of state.
• I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.
• I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

BY USING OR OTHERWISE ACCESSING OUR SERVICES, AND/OR BY REGISTERING WITH US, YOU AGREE TO ONCALL HEALTHCARE'S FINANCIAL & OFFICE POLICIES AND UNDERSTAND THE FOLLOWING:​

INSURANCE (All Patients): OnCall Healthcare does not bill or work directly with ANY insurers. All services (including Medicare/Medicaid) are non-covered services and patients are solely responsible for payment. We offer a competitive cash pay fee schedule. You will be charged the appropriate amount from our standard fee schedule (https://www.oncallhc.com/book-online) and are responsible for payment to hold your appointment. We will, as a convenience to you, provide a "Superbill" to allow the patient to submit for reimbursement if desired.

​

PRESCRIPTIONS, LABS AND ORDERS: Depending on your insurance carrier, patients' insurance may be used for prescriptions, labs and orders. OnCall Healthcare does not participate with ANY insurance carriers and OnCall Healthcare services are non-covered services. As a non-participating and non-covered service, I understand that, in certain cases, patients insurance may not cover prescriptions, labs and orders sent by a non-participating or non-covered service. Patients are responsible for the cost of any prescriptions, labs and/or orders sent on their behalf.

VISIT CANCELLATION POLICY: Due to the time & expense of the intake process & reserving time with your provider, once booked, visit fees are non-refundable.

PAYMENTS: Payment is required to schedule your appointment and reserve time with your provider. Payment can be made online or via invoice.

REFUNDS: All refunds will be issued back to the original method of purchase. Please allow 2-14 days for refund to process.  Merchant processing fees are non-refundable. A 3% fee will be withheld from all refunds to cover non-refundable credit card expenses.

RESCHEDULING: If you need to reschedule please contact our office as soon as possible.

NO SHOWS: If you miss an appointment without notice, you may forfeit your payment.

EQUIPMENT: To participate in online visits you must have the proper equipment, proper internet connection and you must follow the required check in procedures. If you are unable to check in for your appointment due to your equipment, your internet connection or for improper check in procedures, your visit may be canceled and you may forfeit your payment.

PAPERWORK SERVICES: Any paperwork filled out by our providers such as Short-term disability, or FMLA are subject to a $50 Administration Fee.

MEDICAL RECORDS COPIES: Electronic copies of medical records for personal use or for parties other than your health insurance company or other physicians involved with your care are subject to a $30 flat fee. Printed records are subject to a $15 flat fee for the first 10 pages plus $0.50 per page over 10 pages plus shipping.

DELINQUENT ACCOUNT POLICY: Delinquent accounts will be reported to our collection agency. To cover the cost of collections, delinquent accounts balances will be subject to a 45% increase of the overdue amount. Please notify our staff if you know your payment will be late in arriving or if payment arrangements are needed.

DISPUTED PAYMENTS: Disputing payment after services are rendered is considered theft of service. Disputed payments may be reported to local authorities. Late Payment and Delinquent Account Fees may be added to payment disputes.

This financial policy supersedes all prior written financial policies, contracts, or verbal agreements.

You may opt out at any time by emailing us at healthcare@oncallhc.com.