HOPE Dispensary of Greater Bridgeport (HDGB)

Patient Eligibility and Enrollment Forms

2017

HDGB Patient Enrollment English

Patient Name: _______________________________Gender □F □M Patient ID: _______________

Date of Birth: ____-______-_______ Born in USA? □ Yes □ No Patient Phone #: (_____)_____-_________

Preferred Language: □ English □ Spanish□ Portuguese □ French□ Haitian CreoleOther______________

Patient Address: __________________________________________________________________________________

City: _______________________________State: ___________________ Zip Code: _________________________

Employed: □ Yes □ No Do you have a □ Social Security # or □ Tax ID? Number ________________

Insurance: □ Yes □ No If Yes, Name of Insurance: _______________________________________

If yes, do you have a: □ High deductible □ Spend down, Or are you in a □ Coverage Gap

Do you □ Own or □ Rent? Number of Adults (over 18) in home _________

Number of Children under 18 _________

Referral Clinic & Location: _______________________________________________________________________

Allergies- Drug, Food, Chemicals

Type of Reaction

Medications you take: Name & Strength

Directions

Indication

HDGB Patient Enrollment Spanish

Nombre: ____________________________________ Número de Identificación: _____________ Género □F □M

Fecha de Nacimiento: _____-_____-_________ ¿Nacido en USA? □ Si □ No

Número de Teléfono: (_____) _______-________

Idioma Preferido: □ Inglés □ Español□ Portugués □ Francés□ Haitian Creole Alternativa______________

Dirección del Paciente: ________________________________________________________________________________

Ciudad: _________________________ Estado: ________________________ Código Postal: ______________________

¿Está usted empleado? □ Si □ No ¿Usted tiene número de □ Seguro Social o □ Identificación de Impuesto? Numero ______________________

¿Tiene Seguro Médico? □ Si □ No

Nombre de su Seguro Médico: _______________________________

Si tiene seguro, Usted tiene: Alta Deducción Falta de Cobertura

Gastos de su bolsillo

Vivienda: □ Propio o □ Arriendo Numero de Adultos: __________

Niños menores de 18 años: _________

Clínica y Localización: _________________________________________________________

Alergias – Medicamentos, Comida, Químicos

Tipo de Reacción

Medicamentos que tome: Nombre y Dosis

Instrucciones

Indicación

HDGB Provider of Food & Shelter English & Spanish

This letter is the verify that I am providing food and shelter

for ________________________________(Patient) at my home

Address _____________________Town ___________State ___ Zip Code:______

Patient Name: ________________Provider Name :____________________

Signature: _________________ Signature: ________________________

Date______________________Date _____________________________

Esta carta es para verificar que estoy proporcionando comida y refugio

para_________________________________________________(Paciente)

en mi direcciόn__________________________________

Publeo ___________ Estado___ Cόdigo postal:______

Nombre del paciente: ________________Proveedor:______________

Firma: ____________________ Firma: ________________________

Fecha: ____________________Fecha: ________________________

HDGB HIPAA & Signature for Receipt of Privacy Notice English

AUTHORIZATION FOR RELEASE

OF PROTECTED HEALTH INFORMATION

By signing this form, I, ___________________________(or my authorized representative), authorize the use and disclosure of my protected health information ("PHI") as follows:

· Information to be used or disclosed.

All Protected Health Information (PHI) about me created or received by the Hope Dispensary of Greater Bridgeport, the Greater Bridgeport Primary Care Action Group, the Dispensary of Hope,

LLC, and all charitable clinics, charitable pharmacies, drug companies, including drug company assistance programs, and other providers ("Providers") who take part in the Dispensary of Hope Drug Company Assistance Program ("Program") may be used or shared. Your PHI includes your health records, prescription information and other information that could identify you. I understand the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and/or drug abuse.

· People and groups authorized to use, disclose and receive my PHI. Any provider may use my PHI or disclose my PHI to any other provider within the Program.

· Purpose of use or disclosure of my PHI. Providers may use, share and store my PHI to create a common health record for me within the Program; to gather and disclose information to receive grants for or donations to the Program; to determine what types of drugs are used or needed in the Program; and to gather demographic information about patients enrolled in the Program. Providers will not sell or be paid for using or sharing my PHI.

· Expiration of this authorization. This authorization will remain in effect until the Program no longer involves the charitable donation of prescription drugs or unless I stop it.

I understand that I do not have to sign this authorization in order to receive treatment from Hope Dispensary of Greater Bridgeport or any Provider. My treatment, payment, enrollment and eligibility for benefits will not be conditioned on signing this authorization.

I understand that I may revoke this authorization at any time except to the extent that the Providers have taken action based on this authorization. I understand that the revocation will not apply to information that has already been released in response to this authorization. My stopping this authorization will not affect my treatment from the Hope Dispensary of Greater Bridgeport or any Provider. To stop this authorization, I must write to: Hope Dispensary of Greater Bridgeport, 752 East Main Street #170, Bridgeport, Connecticut 06606.

I acknowledge that my PHI disclosed under this authorization might be re-disclosed by the recipient and this re-disclosure may no longer be protected by federal or state law. I understand that I may inspect or have copies made of the information to be used or disclosed, as provided in CFR 164.524.

Hope Dispensary of Greater Bridgeport will provide me with a copy of this signed authorization. I have read (or had read to me) and understand the terms of this Authorization. I have been able to ask questions about the use and sharing of my health information. I knowingly and voluntarily give my permission to the Providers to use or share my health information as described above.

Signature of Patient or Authorized RepresentativeDate

Relationship (if Authorized Representative)

Patient Navigator or Authorized Eligibility QualifierDate

Patient Name:___________________DOB: ___________________

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge receipt of the Hope Dispensary of Greater Bridgeport’s Notice of Information Practices that describes how medical information about may be used and disclosed and how I can get access to this information.

________________________________

Patient Initials

I attest that the information provided to Hope Dispensary of Greater Bridgeport regarding my employment, income and insurance is accurate to the best of my knowledge. I will notify Hope Dispensary of any changes in employment, income or insurance prior to further dispensing or refilling of medication.

SIGNATURE OF PATIENT OR AUTHORIZED REPRESENTATIVEDATE

RELATIONSHIP (IF Authorized REPRESENTATIVE)

PATIENT NAVIGATOR OR AUTHORIZED ELIGIBILITY QUALIFIERDATE

HDGB HIPAA & Signature for Receipt of Privacy Notice Spanish

AUTORIZACIÓN PARA LA DIVULGACIÓN

INFORMACIÓN DE SALUD PROTEGIDA

Hope Dispensary de Greater Bridgeport

Al firmar esta forma, yo, _____________________ (o mi representante autorizado), autorizo el uso y divulgación de mi información de salud protegida ("PHI") de la siguiente manera:

• Información a ser utilizada o divulgada.

Toda la información médica protegida (PHI) de mí creada o recibida por el Hope Dispensary de Greater Bridgeport, the Greater Bridgeport Primary Care Action Group, el Dispensary de Hope,

LLC, y toda caridad clínicas, farmacias benéficas, compañías farmacéuticas, incluyendo los programas de asistencia de las compañías farmacéuticas y otros proveedores ("Proveedores") que participan en el Dispensary of Hope Drug Company Assistance Program ("Programa") de pueden ser usados o compartidos. Su PHI incluye su historia clínica, información de receta farmacéutica y otra información que pudiera identificarlo. Entiendo que la información en mi expediente de salud puede incluir información relacionada con enfermedades de transmisión sexual, síndrome de inmunodeficiencia adquirida (SIDA), o el virus de la inmunodeficiencia humana (VIH). También puede incluir información sobre los servicios de salud del comportamiento o mentales y el tratamiento para el abuso de drogas y / o alcohol.

• Las personas y grupos autorizados a usar, revelar y recibir mi PHI. Cualquier proveedor puede utilizar mi PHI o divulgar mi PHI a cualquier otro proveedor en el Programa.

• Propósito de uso o divulgación de mi PHI. Los proveedores pueden utilizar, compartir y almacenar mi PHI para crear un registro de salud común para mí dentro del Programa; para recopilar y divulgar información para recibir subvenciones o donaciones para el Programa; para determinar qué tipos de medicamentos se utilizan o necesario en el Programa; y para recopilar información demográfica sobre los pacientes incluidos en el Programa. Los proveedores no podrán vender o ser pagado por el uso o compartir mi PHI.

• Vencimiento de la presente autorización. Esta autorización se mantendrá en efecto hasta que el programa ya no consiste en la donación de caridad de los medicamentos recetados o menos que detenerlo.

Entiendo que no tengo que firmar esta autorización para recibir tratamiento de Hope Dispensary de Greater Bridgeport o cualquier Proveedor. Mi tratamiento, pago, receta farmacéutica y elegibilidad para beneficios no estarán condicionados a la firma de esta autorización.

Entiendo que puedo revocar esta autorización en cualquier momento, excepto en la medida en que los proveedores han tomado acción basada en esta autorización. Entiendo que la revocación no se aplicará a la información que ya ha sido lanzado en respuesta a esta autorización. Mi detener esta autorización no afectará mi tratamiento de Hope Dispensary de Greater Bridgeport o cualquier Proveedor. Para detener esta autorización, debo escribir a: Hope Dispensary de Greater Bridgeport, 752 East Main Street # 170, Bridgeport, Connecticut 06606.

Reconozco que mi PHI divulgada bajo esta autorización puede ser revelada por el destinatario y esta re-divulgación puede no estar protegida por la ley federal o estatal. Entiendo que puedo inspeccionar o obtener copias de la información para ser utilizada o revelada, según lo dispuesto en el CFR 164.524.

Hope Dispensary de Greater Bridgeport me proporcionará una copia de esta autorización firmada. He leído (o se me ha leído) y entiendo los términos de esta autorización. He podido hacer preguntas sobre el uso y el intercambio de información sobre mi salud. A sabiendas y voluntariamente doy mi permiso a los proveedores para utilizar o compartir mi información de salud como se describe anteriormente.

__________________________________________________________________________

Firma del paciente o representante autorizado Fecha

 ___________________________________________

Relación (si Representante Autorizado)

___________________________________________________________________________

Administrador De Casos O Elegible Calificador Autorizado Fecha

Nombre del paciente: ___________________ Fecha de nacimiento: ___________________

RECONOCIMEINTO DE RECIBO DEL AVISO DE PRÁCTICAS DE PRIVACIDAD

Acuso recibo de Hope Dispensary de Greater Bridgeport del Aviso de Prácticas de información que describe cómo la información médica puede ser usada y divulgada y cómo puedo tener acceso a esta información.

 ________________________________

           Iniciales del paciente

Doy fe de que la información proporcionada al Hope Dispensary de Greater Bridgeport con respecto a mi empleo, los ingresos y el seguro es exacta al mejor de mi conocimiento. Notificaré Hope Dispensary de cualquier cambio en el empleo, el ingreso o el seguro antes de la dispensación más o recargar la medicación.

_______________________________________________________________________

FIRMA DEL PACIENTE O REPRESENTANTE AUTORIZADO FECHA

 _____________________________________________________

RELACIÓN (SI representante autorizado)

______________________________________________________________________________

ADMINISTRADOR DE CASOS O ELEGIBLE CALIFICADOR AUTORIZADO FECHA

HDGB Income Documentation English/Spanish/ Portuguese

This letter is to document that I provide employment for

_____________________ (Print Employee)

Type of work done_________________________________________

Amount paid per month: ____________________________________

_____________________________________________________

Signature of EmployerPrint EmployerDate

____________________________________

Signature of EmployeeDate

Spanish

Esta carta es para documentar que proveo trabajo para __________________(empleado/a)

Tipo de trabajo hecho:_________________________________________

Pago por mes:

____________________________________

______________________________________________________

Firma del/la empleador/aEscribe del/la empleador/aFecha

____________________________________

Firma del/a empleado/aFecha

Portuguese

Esta carta é para documentar que eu proveio trabalho para __________________(empregado/a)

Tipo de trabalho que faz:_________________________________________

Pagamento por mês:

____________________________________

______________________ ________________________________

Firma do/a empregador/a Escribe del/la empleador/aData

____________________________________

Firma do/a empregadoData

HDGB Documentation Receipt of Privacy Practices/New Patient Signature Log

Hope Dispensary of Greater Bridgeport

752 East Main St. #170 Bridgeport, CT 06608 Tel. (203) 332-5653 / fax (203) 576-7491

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received a copy off the Hope Dispensary of Greater Bridgeport's Notice of Privacy Practices.

DATE

DOH ID NUMBER

NAME

SIGNATURE OF PATIENT OR AUTHORIZED REPRESENTATIVE

RELATIONSHIP (IF AUTHORIZED REPRESENTATIVE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HDGB Privacy Practices English

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

YOU SHOULD ALSO SHARE A COPY OF THIS NOTICE WITH YOUR FAMILY MEMBERS, FRIENDS, ETC. WHO ARE ACTIVELY INVOLVED IN YOUR HEALTH CARE.

This Notice affirms that the Hope Dispensary of Greater Bridgeport (“we” or “us”) is dedicated to maintaining the privacy of your health information. In our operations, we create records regarding you and the benefits/services we provide you. This Notice will tell you about the ways in which we may use and disclose medical information about you. We will also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We are required by law to:

· Maintain the privacy of your health information, also known as PHI

· Provide you with this Notice, and

· Comply with this Notice.

We reserve the right to change our privacy practices and to make any such change applicable to the PHI we obtained about you before the change. If there is a material revision to this Notice, we will distribute the new Notice to you within 60 days of the revision. You may obtain a paper copy of the current Notice by contacting the Hope Dispensary of Greater Bridgeport using the contact information we provide at the end of this Notice.

HOW THE HOPE DISPENSARY OF GREATER BRIDGEPORT MAY USE AND DISCLOSE YOUR PHI

The law permits us to use and disclose your PHI for certain purposes without your permission or authorization. The following gives examples of each of these circumstances.

1. For Treatment. We may use or disclose your PHI for purposes of treatment. For example, we may disclose your PHI to physicians, nurses and other professionals who are involved in your care.

2. For Payment. We may use or disclose your PHI to provide payment for, or stock replenishment of the treatment you receive under the Hope Dispensary of Greater Bridgeport or Dispensary of Hope, LLC benefit.

3. For Health Care Operations. We may use or disclose your PHI for our health care operations. For example, we may verify periodically your eligibility status with the state Medicaid system or other insurance benefits, which may be responsible for the cost-management and planning of your medications.

4. To the Plan Sponsor. We may disclose your PHI to the Hope Dispensary of Greater Bridgeport or Dispensary of Hope, LLC executive and planning personnel only for purposes of maintaining your eligibility for enrollment in the plan.

5. For Health Related Plans and Services. The Hope Dispensary of Greater Bridgeport or the Dispensary of Hope, LLC may contact you about information regarding treatment alternatives or other health-related benefits and services that may be of interest to you.

6. To Individuals Responsible for Your Care. We may disclose your PHI to a family member or friend who is involved in your medical care provided that you agree to this disclosure, or we give you the opportunity to object to this disclosure. However, if you are unavailable or are unable to agree or object, we will use our best judgment to decide whether this disclosure is in your best interest.

7. Fundraising. We may communicate with you as part of our fundraising activities, but you have the right to opt-out of receiving such communications.

OTHER USES OR DISCLOSURES OF YOUR PHI WITHOUT AN AUTHORIZATION

The law allows us to disclose your PHI in the following circumstances without your permission or authorization.

1. When Required by Law. We will use and disclose your PHI when we are required to do so by federal, state, or local law.

2. For Public Health Risks. We will use and disclose your PHI for public health activities, such as those aimed at preventing or controlling disease, preventing injury, reporting reactions to medications or problems with products and reporting the abuse or neglect of children, elders and dependent adults.

3. For Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities authorized by law. These oversight activities, which are necessary for the government to monitor the health care system, include investigations, inspections, audits and licensure.

4. For Lawsuits and Disputes. We may use or disclose your PHI in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We may also disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request of obtaining an order protecting the information the party has requested.

5. To Law Enforcement. We may release PHI if asked to do so by a law enforcement official for the following circumstances:

· Concerning a death we believe might have resulted from criminal conduct;

· Regarding criminal conduct at our offices;

· In response to a warrant, summons, court order, subpoena or similar legal process;

· To identify/locate a suspect, material witness, fugitive or missing person;

· In an emergency, to report a crime (including the location or victim(s) of the crime, the description, identity or location of the person who committed the crime).

6. To avert a Serious Threat to Health or Safety. We may use or disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosure to a person or organization able to prevent the threat.

7. For Military Functions/National Security. Your PHI may be disclosed if you are a member of the US or foreign military forces and if required to by the appropriate military command authorities. We may also disclose PHI about you to federal officials for intelligence and national security activities authorized by law. We may also disclose PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

8. Inmates. We may disclose PHI to a correctional facility if you are an inmate or under the custody of a law enforcement official.

WHEN YOUR WRITTEN AUTHORIZATION IS REQUIRED

We must obtain your written authorization before:

· Using or disclosing your psychotherapy notes, except for (i) use by the originator of the psychotherapy notes for treatment, (ii) use or disclosure by us for our own mental health training programs, or (iii) use or disclosure to defend ourselves in a legal action or other proceeding brought by you.

· Using or disclosing your PHI for marketing purposes, except for face-to-face communications made by us to you or a promotional gift of nominal value provided by us to you.

· Any other use or disclosure of your PHI that is not covered by this Notice.

YOUR RIGHTS RELATED TO YOUR PHI

You have the following rights regarding your PHI that we maintain.

1. Right to Request Confidential Communication – You may request that we only communicate your PHI by certain methods and in certain locations. For example, you may request that we only contact you about your PHI in writing, or at a particular residence.

2. Right to Request Restrictions in use of your PHI - You may request a restriction on our use or disclosure of you PHI. For example, you may request that we not disclose any information to a family member who may be involved in your care.

3. Right to Inspect and Copy your PHI - You may request access to and copies of your PHI maintained by us. We will provide you access to your PHI within 30 days after receipt of your request (or 60 days if the information is stored off-site). You may be charged for any costs associated with copying and mailing.

4. Right to Request Amendment to your PHI - You may request that we amend or correct any of your PHI that you believe to be inaccurate for as long as such PHI remains in our records. We will respond to your request within 60 days of receipt, subject to extension if necessary.

5. Right to an Accounting of Disclosures - You may request an accounting of all disclosures we have made of your PHI in the 6 years prior to your request. We will provide such accounting within 60 days of your request, subject to extension if necessary. The first accounting will be provided free of charge, but each subsequent accounting within the same 12 month period may be subject to a fee.

6. Right to Notification in Event of Breach – We are required to notify you in the event of a breach of your unsecured PHI.

We are not required to agree to your requests (except for when you request that we not disclose information to your health plan about services for which you paid out-of-pocket in full), but will do everything within our means to accommodate any legitimate request.

IF YOU BELIEVE YOUR PRIVACY RIGHTS HAVE BEEN VIOLATED, YOU MAY FILE A COMPLAINT WITH THE HOPE DISPENSARY OF GREATER BRIDGEPORT’S PRIVACY OFFICER, OR WITH THE SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES.

To file a complaint with us, you must submit in writing to the address listed at the end of this Section. We will not retaliate against you for filing a complaint.

If you have questions about this Notice or would like to exercise one or more of the rights listed in this Notice, please contact: The Hope Dispensary of Greater Bridgeport, 752 East Main Street #170, Bridgeport, CT 06606, Telephone (203) 332-5653, or The Secretary of the Department of Health and Human Services, Hubert H. HumphreyBuilding, 200 Independence Avenue SW, Washington, DC. 20201.

ADDITIONAL CONNECTICUT REQUIREMENTS

Disclosure - We will not disclose information about pharmaceutical services rendered to you to third parties without your consent, except to the following persons:

1. The prescribing practitioner or a pharmacist or another prescribing practitioner presently treating you when deemed medically appropriate;

2. A nurse who is acting as an agent for a prescribing practitioner that is presently treating you or a nurse providing care to you in a hospital;

3. Third party payors who pay claims for pharmaceutical services rendered to you or who have a formal agreement or contract to audit any records or information in connection with such claims;

4. Any governmental agency with statutory authority to review or obtain such information;

5. Any individual, the state or federal government or any agency thereof or court pursuant to a subpoena; and

6. Any individual, corporation, partnership or other legal entity which has a written agreement with the pharmacy to access the pharmacy's database provided the information accessed is limited to data which does not identify specific individuals.

Sale of Information - We will not sell your individually identifiable medical record information.

Revised 9.23.13

HDGB Privacy Practices Spanish