White Cross Pharmacy 602 Main Street Brawley, CA 92227 Phone 760-344-3131 Fax 760-344-4676 Notification of Information Practices The purpose of the consent form is to inform you, the patient, how your personal health information is used and/or disclosed by this provider or organization. We want you to be fully aware of what we do with your information so that you can provide us with your consent in order for us to treat your health care needs, receive payment for services rendered, and allow administrative and other types of health care operations to happen, which are part of normal business activities of the provider or organization. Your consent I understand that as part of my health care, this organization originates and maintains health records describing my health history, symptoms, test results, diagnoses, treatment, and plans for future care or treatment. I understand that this information serves as: * A basis for planning my care and treatment. * A means of communication among my diagnosis/es and other health information to my bill(s). * A source of information for applying my diagnosis/es and other health information to my bill(s). * A means by which my health plan or health insurance company can verify that services billed were actually provided. * A tool for routine health operations in this organization, such as ensuring that we have quality processes and programs in place and making sure that the professionals who provide your care are competent to do so. I understand that: * I have been provided with a Notice of Information Practices that provides specific examples and descriptions of how my personal health information is used and disclosed by White Cross Pharmacy; * I have the right to review the Notice of Information Practices prior to signing this consent; * White Cross Pharmacy can change its Notice of Information Practices but notify me of those changes before they are put into practice and will mail me a copy of the new Notice to the address that I have provided; * I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations and that White Cross Pharmacy is not required to agree to those restrictions; * Any restriction to which White Cross Pharmacy agrees to will be respected; * I may revoke this consent in writing at any time, Further, I am aware that White Cross Pharmacy can proceed with uses and disclosures that pertain to treatment, payment, or healthcare issues that took place before the consent was revoked. Patient Rights: 1. The patient has the right to considerate and respectful service. 2. The patient has the right to obtain service without regard to race, creed, national origin, sex, age, disability diagnosis, or religious affiliation. 3. Subject to applicable law, the patient has the right to confidentiality of all information pertaining to his/her medical equipment service. Individuals or organizations not involved in the patient?s care may not have access to the information without the patient?s written consent. 4. The patient has the right to make informed decisions about his/her care. 5. The patient has the right to reasonable continuity of care and service. 6. The patient has the right to voice grievances without fear of termination of services or other reprisal in the service process. Patient Responsibilities: 1. The patient should promptly notify the Home Medical Equipment Company of any equipment failure or damage. 2. The patient is responsible for any equipment that is lost or stolen while in their possession and should promptly notify Home Medical Equipment Company in such instances. 3. The patient should promptly notify the Home Medical Equipment Company of any changes to their address or telephone. 4. The patient should notify the Home Medical Equipment Company of any changes concerning their physician. 5. The patient should notify the Home Medical Equipment Company of discontinuance of use. 6. Except where contrary to federal or state law, the patient is responsible for any equipment rental and sale charges which the patient?s insurance company does not pay.