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I understand that I will be responsible for payment of all services provided.
Note: There is a 24-hour cancellation fee of $100.

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
EFFECTIVE DATE : 1/5/2009
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!
The office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination, and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.
Examples of Uses of Your Health Information for Treatment Purposes are:
• A nurse obtains treatment information about you and records it in a health record.
• During the course of your treatment, the physician determines he/she will need to consult with another specialist in the area. He/she will share the information with such specialist and obtain his/her input.
Example of Use of Your Health Information for Payment Purposes:
We submit requests for payment to your health insurance company. The health insurance company (or other business associate helping us obtain payment) requests information from us regarding medical care given. We will provide information to them about you and the care given.
Example of Use of Your Information for Health Care Operations:
We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guideline development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.
Your Health Information Rights
The health and billing records we maintain are the physical property of the office. The information in it, however, belongs to you. You have a right to:
• Request a restriction on certain uses and disclosures of your health information by delivering the request to our office -- we are not required to grant the request, but we will comply with any request granted;
• Obtain a paper copy of the current Notice of Privacy Practices for Protected Health Information ("Notice") by making a request at our office;
• Request that you be allowed to inspect and copy your health record and billing record – you may exercise this right by delivering the request to our office;
• Appeal a denial of access to your protected health information, except in certain circumstances;
• Request that your health care record be amended to correct incomplete or incorrect information by delivering a request to our office/hospital. We may deny your request if you ask us to amend information that:
• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the health information kept by or for the office/hospital;
• Is not part of the information that you would be permitted to inspect and copy; or,
• Is accurate and complete.
If your request is denied, you will be informed of the reason for the denial and will have an opportunity to submit a statement of disagreement to be maintained with your records;
• Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office/hospital;
• Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a request to our office/hospital. An accounting will not include uses and disclosures of information for treatment, payment, or operations; disclosures or uses made to you or made at your request; uses or disclosures made pursuant to an authorization signed by you; uses or disclosures made in a facility directory or to family members or friends relevant to that person's involvement in your care or in payment for such care; or, uses or disclosures to notify family or others responsible for your care of your location, condition, or your death.
• Revoke authorizations that you made previously to use or disclose information by delivering a written revocation to our office/hospital, except to the extent information or action has already been taken.
If you want to exercise any of the above rights, please contact SABITA NANDY, 1525 E. 53rd St. Suite 433, Chicago, IL 606015, Phone: 312 607 4277, in person or in writing, during regular, business hours. [S]he will inform you of the steps that need to be taken to exercise your rights.

Consent to Treat/Bill & Privacy Information Form

Thank you for choosing Sabita Nandy LLC. Please review the form below so we can provide the optimal care for you, bill appropriately, and share your information securely.


CONSENT FOR TREATMENT
By signing this form, I consent to and authorize my provider(s) at Sabita Nandy LLC (SNLLC) to treat me or my dependent. I understand this could include behavioral health interventions. I understand that my provider is available to explain the treatment and I have the right to refuse treatment. I understand that this consent will be valid and remain in effect as long as I attend any of the offices of SNLLC.

CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION
I hereby authorize SNLLC to release any information acquired in the course of my examination and treatment to any authorized agent for the purposes of healthcare, treatment, and payment. I authorize the release of behavioral health information to my insurers as necessary for determination and payment of benefits; to utilization review and professional standards review organizations, companies, and community resources that assist me with my healthcare needs.

NOTIFICATION OF PRIVACY
SNLLC complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I have received the SNLLC Notice of Privacy Practices.

CONSENT TO BILL, ASSIGNMENT OF BENEFITS, AND PAYMENT
I authorize SNLLC to file a claim with my insurance carrier for services rendered. I authorize SNLLC payment of benefits directly to SNLLC, for services provided to my dependent or me. I understand that I am responsible for any part of the charges that are not covered/paid by my insurance and I will be billed directly for those services.

** If you are uninsured, please note that your account is your responsibility. Please inquire for more details. The parent or legal guardian of a minor patient (under 18 years of age) is responsible for payment on the minor’s account.**

ACKNOWLEDGEMENT OF PERSONAL PROPERTY
I understand that SNLLC shall not be liable for loss or damages of any personal property.

MENTAL HEALTH CRISIS/EMERGENCY
If you have a mental health crisis or need to speak to someone, please call Suicide Prevent Lifeline at 988 at any time, or call 911, or go to your nearest hospital emergency department; they are there to help you.
LIMITS OF CONFIDENTIALITY
We are permitted or required, under specific circumstances, to use or disclose protected health information without your written authorization: suicidal urges (being a danger to yourself), homicidal urges (being a danger to others), court order/subpoena, child abuse/neglect, and elder or vulnerable adult abuse/neglect.

I understand that I may revoke this consent in writing; however, my revocation will not apply to information already used or released in reliance on this consent. I agree that a copy of this consent may be used in place of the original. I also understand that by refusing to sign this consent or revoking this consent, this organization may not be able to provide services to me.