Upon admission to care, all Patients shall be informed of their responsibilities and how to use any orthotic or prosthetic device delivered.
1. A copy of the Patient Responsibilities statement shall be distributed to each individual upon admission to service. The Patients shall acknowledge receipt of the Patient Responsibilities statement by their signature and date.
2. A copy of the Patient Responsibilities shall be distributed to each staff member as part of their orientation process, and the contents shall be reviewed by the individual conducting the orientation.
3. All staff members and others providing services on behalf of FRONT RANGE ORTHOTICS are expected to be aware of the Patient Responsibilities.
4. The Patient Responsibilities are incorporated into FRONT RANGE ORTHOTICS.'s policies and procedures and shall be made available to other organizations and the interested public upon request.
5. The following represents FRONT RANGE ORTHOTICS.'s Patients Responsibilities:
THE PATIENT'S RESPONSIBILITIES
FRONT RANGE ORTHOTICS and its personnel have the right to expect behavior on the part of patients and their relatives and friends, which considering the nature of their illness and predicament, is reasonable. These responsibilities include but are not limited to the following:
-Give accurate and complete health information concerning your past illnesses, hospitalization, medications, allergies, infections, diseases and other pertinent items.
-Assist in developing and maintaining a safe environment.
-Inform FRONT RANGE ORTHOTICS when you will not be able to keep an appointment.
-Participate in the development of and adhere to your homecare plan of service/treatment.
-Request further information concerning anything you do not understand.
-Contact your doctor whenever you notice any change in your condition.
-Contact FRONT RANGE ORTHOTICS whenever you have a problem with a device
-Contact FRONT RANGE ORTHOTICS whenever you have received a change in your prescription
-Give information regarding concerns and problems you have to FRONT RANGE ORTHOTICS.
-Ensure that the financial obligation for your orthotic or prosthetic is met promptly.
Your Privacy Rights
You have the following rights with respect to PHI about you:
Obtain a Paper Copy of the Notice Upon Request. You may request a copy of the most current version of this Notice at any time. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy. To obtain a paper copy, contact FRONT RANGE ORTHOTICS's Chief Privacy Officer, Address:255 Union Blvd Ste 380 Lakewood CO 80228 . Inspect and Obtain a Copy of PHI. You have the right to inspect and obtain a copy of the PHI about you contained in a designated record set forth as long as FRONT RANGE ORTHOTICS maintains the PHI. The "designated record set" usually will include prescriptions, physician orders, and billing records. To inspect or receive a copy of your PHI for your inspection, you must send a written request to Privacy Officer, Address:255 Union Blvd Ste 380 Lakewood CO 80228.
Under federal law, however, you may not inspect or copy the following records: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. We may charge you a fee for the costs of copying, mailing, or other supplies that are necessary to grant your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to PHI about you, you may request that the denial be reviewed.
Request an Amendment of PHI. If you feel that PHI we maintain about you is incomplete or incorrect, you may request that we amend it. You may request an amendment for as long as we maintain the PHI. To request an amendment, you must send a written request to the Chief Privacy Officer, Address:255 Union Blvd Ste 380 Lakewood CO 80228 In addition, you must include a reason that supports your request. In certain cases, we may deny your request for amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision and we will reply to your statement.
Request a Restriction on Certain Uses and Disclosures of PHI. You have the right to request restrictions on our use or disclosure of PHI about you by sending a written request to the Chief Privacy Officer, Address:255 Union Blvd Ste 380 Lakewood CO 80228. You may request that any Part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction and to whom you want the restriction to apply. We are not required to agree to those restrictions.
Receive an Accounting of Disclosure of PHI. You have the right to receive an accounting of the disclosures we have made of PHI about you after April 14, 2003 for most purposes other than treatment, payment, or health care operations. The accounting will exclude disclosures we have made directly to you, disclosures to friends or family members involved in your care, incidental disclosures permitted by law, and disclosures for notification purposes. The right to receive an accounting is subject to certain other exceptions, restrictions, and limitations. To request an accounting, you must submit your request in writing to the Chief Privacy Officer, Address:255 Union Blvd Ste 380 Lakewood CO 80228. Your request must specify the time period, but may not be longer than six years. The first accounting you request within a 12-month period will be provided free of charge, but you may be charged for the cost of providing additional accountings. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time.
Request Communication of PHI by Alternative Means or At Alternative Locations. You may request that we communicate with you by an alternative means or at an alternative location. For example, you may request that we contact you about medical matters only in writing or at a different residence or post office box. We will not request an explanation from you as to the basis for the request. To request confidential communication of PHI about you, your must submit your request in writing to the Chief Privacy Officer Address:255 Union Blvd Suite 380 Lakewood CO 80228. Your request must state how, or when, you would like to be contacted. We will accommodate all reasonable requests.
You may complain to FRONT RANGE ORTHOTICS and to the Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint. If you wish to file a complaint, please contact our Chief Privacy Officer at Address: 255 Union Blvd Ste 380 Lakewood CO 80228.
If you have any questions or other concerns, please contact FRONT RANGE ORTHOTICS. Chief Privacy Officer Address:255 Union Blvd Ste 380 Lakewood CO 80228 or Phone: 303.993.4303
Chief Privacy Officer
Effective Date. This Notice was published and becomes effective on January 27, 2015