Patient Rights & Privacy

HIPAA Privacy Notice & Acknowledgment

Please review our Notice of Privacy Practices below and complete the acknowledgment form. This notice describes how your health information may be used and disclosed and how you can access this information.

Blessed Hands Mobile Phlebotomy Services

Notice of Privacy Practices

Our Commitment to Your Privacy

Blessed Hands Mobile Phlebotomy Services, LLC is committed to protecting the privacy of your health information. We are required by law to maintain the privacy of your Protected Health Information (PHI), provide you with this notice of our legal duties and privacy practices, and follow the terms of the notice currently in effect.

How We May Use and Disclose Your Health Information

Treatment: We may use and disclose your PHI to provide, coordinate, or manage your healthcare and related services, including sharing information with other healthcare providers involved in your care.
Payment: We may use and disclose your PHI to obtain payment for services rendered, including billing your insurance company or other payers.
Healthcare Operations: We may use and disclose your PHI for our internal operations, such as quality assessment, training, and compliance activities.
As Required by Law: We will disclose your PHI when required to do so by federal, state, or local law.
Public Health Activities: We may disclose your PHI for public health activities as permitted or required by law.
Health Oversight: We may disclose your PHI to health oversight agencies for activities authorized by law, such as audits and investigations.
Business Associates: We may share your PHI with third-party business associates who perform services on our behalf, provided they agree to protect the privacy of your information.

Uses and Disclosures Requiring Your Authorization

Other uses and disclosures of your PHI not described in this notice will be made only with your written authorization. You may revoke your authorization at any time in writing, except to the extent that we have already taken action in reliance on it.

Your Rights Regarding Your Health Information

Right to Inspect and Copy: You have the right to inspect and obtain a copy of your PHI that we maintain in a designated record set.
Right to Amend: You have the right to request an amendment to your PHI if you believe it is incorrect or incomplete.
Right to an Accounting of Disclosures: You have the right to request a list of disclosures we have made of your PHI, other than for treatment, payment, or healthcare operations.
Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your PHI. We are not required to agree to your request, except in limited circumstances required by law.
Right to Request Confidential Communications: You have the right to request that we communicate with you about your health information in a certain way or at a certain location.
Right to a Paper Copy of This Notice: You have the right to receive a paper copy of this notice at any time.
Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services Office for Civil Rights. You will not be penalized for filing a complaint.

Changes to This Notice

We reserve the right to change this notice and to make the revised notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our office and on our website.

Contact Information

For questions about this notice or to exercise your rights, please contact us at: [email protected] or call 432.701.8903.

Patient Information

Patient Full Name*

Date of Birth*

Phone*

Address

Personal Representative (if applicable)

Complete this section only if a personal representative (parent, legal guardian, or authorized representative) is signing on behalf of the patient.

A personal representative is completing this form

Optional Requests

I would like to request a restriction on certain uses or disclosures of my health information

I would like to request confidential communications at an alternate address or phone number

Acknowledgment of Receipt

By signing below, I acknowledge that I have received and/or had the opportunity to review the Notice of Privacy Practices of Blessed Hands Mobile Phlebotomy Services, LLC. I understand that this notice describes how my health information may be used and disclosed and how I can access this information.

Patient / Representative Signature*

Date*

For Staff Use Only

Staff Member Name

Date

If the patient or personal representative refused to sign or was unable to sign, please note the reason in the special instructions of the booking request or contact the office directly.