Waiver and Release
I, the patient, acknowledge that I am independently selecting on my own behalf or on the behalf of the minor as the
minor’s parent or legal guardian, to participate in the use of the Inhouse Physicians website and/or mobile app to upload
COVID-19 vaccine status and/or self-administered COVID-19 test(s) for the purposes of InHouse Physicians (IHP) to provide
COVID-19 clearance verification via self-test COVID-19 test result submission(s) or vaccination status to myself and my
affiliated sponsor, organization, employer, or school (SPONSOR). I, the patient, acknowledge that I have followed the
instructions for COVID-19 self-test administration as outlined by the test manufacturer. I understand that test results
submitted through the InHouse Physicians’ website and/or mobile app may be reported to federal, state, and/or local
entities as required by regulations. I agree to waive and release any and all claims, actions, causes of action, demands,
expenses, or liabilities of whatsoever kind and nature, including without limitation, consequential loss, attorney’s fees
and expenses, court costs, and costs of investigation, against the SPONSOR as well as its employees, agents, officers
and directors, which may arise out of the COVID-19 testing provided by the SPONSOR and IHP, its employees, agents,
officers, or contractors. Upon referral to another medical provider, by IHP, you further hereby release IHP and its employees,
agents, officers, directors and shareholders, from and against any and all claims, losses, liabilities or expenses arising, in
whole or in part, out of care or treatment by the medical provider to whom the referral was made.
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The above waiver and release is not intended to waive your rights to workers’ compensation benefits for which you may
become eligible as a result of any work-related injury, nor is it intended to waive your rights to any benefits you or other
covered person might have under a company sponsored insurance benefit or medical plan.
Consent and Representations
You hereby represent that you have carefully read the above information regarding informed consent and fully understand
the implications thereof. You hereby consent to the conditions outlined above concerning COVID-19 self-test administration,
COVID-19 test result submission, and/or vaccine record submission. You hereby consent to the conditions outlined above
concerning the sharing of your COVID-19 test clearance verification and/or vaccine status to you SPONSOR and the federal,
state, and local entities as required by regulations.
NOTICE OF PRIVACY PRACTICES
The law requires InHouse Physicians to keep your protected health information (PHI) private in accordance with this Notice of
Privacy Policies (Notice), as long as this Notice remains in effect. We are also required to provide you with a paper copy of this
Notice, which contains our privacy practices, our legal duties, and your rights concerning your PHI. From time to time, we may
revise our privacy practices and the terms of our Notice at any time, as permitted or required by applicable law. Such revisions
to our privacy practices and our Notice may be retroactive. Our Notice will be updated and made available to our patients prior
to any significant revisions of our privacy practices and policies.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Who We Are
This Notice describes the privacy practices of InHouse Physicians.
II. Our Privacy Obligations
We are required by law to maintain the privacy of your health information ("Protected Health Information" or "PHI") and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).
III. Permissible Uses and Disclosures Without Your Written Authorization
In certain situations, which we will describe in Section IV below, we must obtain your written authorization in order to use and/or disclose your PHI. However, we do not need any type of authorization from you for the following uses and disclosures:
A. Uses and Disclosures for Treatment, Payment and Healthcare Operations. We may use and disclose PHI, but not your "Highly Confidential Information" (defined in Section IV. B below), in order to treat you or evaluate or our "healthcare operations" as detailed below:
• Treatment. We use and disclose your PHI to provide treatment and other services to you -- for example, to treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health- related benefits and services that may be of interest to you. We may also disclose PHI to other providers involved in your treatment.
• Healthcare Operations. We may use and disclose your PHI for our healthcare operations, which include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use PHI to evaluate the quality and competence of our physicians, nurses and other healthcare workers. We may also disclose PHI to your other healthcare providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain healthcare operations, such as quality assessment and improvement activities, reviewing the quality and competence of healthcare professionals, or for healthcare fraud and abuse detection or compliance.
B. Disclosure to Relatives, Close Friends and Other Caregivers. We may use or disclose your PHI to a family member, other relative, a close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement; (2) provide you with the opportunity to object to the disclosure and you do not object; or (3) reasonably infer that you do not object to the disclosure. If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure is in your best interests. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the person’s involvement with your healthcare or payment related to your healthcare. We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.
C. Public Health Activities. We may disclose your PHI for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U. S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work- related illnesses and injuries or workplace medical surveillance.
D. Victims of Abuse, Neglect or Domestic Violence. If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose your PHI to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence.
E. Health Oversight Activities. We may disclose your PHI to a health oversight agency that oversees the healthcare system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
F. Judicial and Administrative Proceedings. We may disclose your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
G. Law Enforcement Officials. We may disclose your PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
H. Decedents. We may disclose your PHI to a coroner or medical examiner as authorized by law.
I. Organ and Tissue Procurement. We may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
J. Research. We may use or disclose your PHI without your consent or authorization if an Institutional Review Board or Privacy Board approves a waiver of authorization for disclosure.
K. Health or Safety. We may use or disclose your PHI to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.
L. Specialized Government Functions. We may use and disclose your PHI to units of the government with special functions, such as the U. S. military or the U. S. Department of State under certain circumstances.
M. Workers' Compensation. We may disclose your PHI as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs.
N. As Required by Law. We may use and disclose your PHI when required to do so by any other law not already referred to in the preceding categories.
IV. Uses and Disclosures Requiring Your Written Authorization
A. Use or Disclosure with Your Authorization. For any purpose other than the ones described above in Section III, we only may use or disclose your PHI when you grant us your written authorization ("Your Authorization"). For instance, you will need to execute an authorization before we can send your PHI to your life insurance company or to the attorney representing the other party in litigation in which you are involved.
B. Uses and Disclosures of Your Highly Confidential Information. In addition, federal and state law requires special privacy protections for certain highly confidential information about you ("Highly Confidential Information"). We will comply with such special privacy protections which may cover the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental health and developmental disabilities services; (3) is about alcohol and drug abuse prevention, treatment and referral; (4) is about HIV/AIDS testing, diagnosis or treatment; (5) is about venereal disease(s); (6) is about genetic testing; (7) is about child abuse and neglect; (8) is about domestic abuse of an adult with a disability; (9) is about sexual assault; or (10) is about abortion.
V. Your Rights Regarding Your Protected Health Information
A. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact our Patient Relations Department. You may also file written complaints with the Director, Office for Civil Rights of the U. S. Department of Health and Human Services. Upon request, the Patient Relations Department will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with us or the Director.
B. Right to Request Restrictions. You may request restrictions on our use and disclosure of your PHI (1) for treatment and healthcare operations; (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care; or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While we will consider all requests for restrictions carefully, we are not required to agree to a requested restriction. If you wish to request restrictions, please submit a written request to our Patient Relations Department. A form to request restrictions is available upon request from the Patient Relations Department.
C. Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.
D. Right to Revoke Your Authorization. You may revoke Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your Highly Confidential Information, except to the extent that we have taken action in reliance upon it, by delivering a written revocation statement to the Patient Relations Department identified below. A form of written revocation is available upon request from the Patient Relations Department.
E. Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records, please submit a written request to the Patient Relations Department. You may obtain a record request form from the Patient Relations Department and submit the completed form to the Patient Relations Department. Requests for a copy of a limited amount of your medical or billing records (e. g., a prescription) maintained by us on- site may be made orally to our local facility. We may, however, require that you submit a written request to the Patient Relations Department.
F. Right to Amend Your Records. You have the right to request that we amend Protected Health Information maintained in your medical record file or billing records. If you desire to amend your records, please send a written request for the amendment, including the reason for the amendment, to the Patient Relations Department. You may obtain a form to request an amendment from the Patient Relations Department. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
G. Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made by us during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2020.
H. Right to Receive Paper Copy of This Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.
VI. Effective Date and Duration of This Notice
A. Effective Date. This Notice is effective as of July 1, 2021.
B. Right to Change Terms of This Notice. We reserve the right to, meaning we may, change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in waiting areas at our facility and on our Internet site. You also may obtain any new notice by contacting the Physician and Patient Relations Department.
VII. Patient Relations Department.
You may contact the Patient Relations Department at:
Patient Relations Department
1560 Wall Street, Suite 335, Naperville, IL 60563
Facsimile Number: (630) 584-2707