CONSENT FORMS

CONSENT FORMS
Please complete all pages. Each page is a separate consent form.

Please read all of the information contained in each form before signing.

Each of these forms must be filled out prior to being seen at our office.

Please make sure to click the SUBMIT button on the last page

SUMMARY NOTICE OF HIPAA PRIVACY PRACTICES

HIPAA & 42 CFR Part 2 Patient Notice
This notice describes how your medical information may be used and disclosed and you may obtain this information. Please review it carefully.

Hematology and Oncology Associates of Northern California (HOAONC) is commited to protecting the privacy and confidentiality of your health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and, where applicable, 42 CFR Part 2, which provides additional protections for certain substance use disorder treatment records.

Our Commitment to Your Privacy

We understand that your medical information is personal. We are committed to protecting the priivacy of your health information and maintaining the confidentiality of your medical records.

We are required by law to:
- Maintain the privacy and security of your protected health information (PHI)
- Provide you with this notice explaining our legal duties and privacy practices
- Follow the terms of this notice
- Notify you if a breach occurs that may compromise the privacy or security of your information
What Information Is Protected

Protected Health Information (PHI) includes information about:
- Your health condition
- Medical treatments and services
- Medications
- Lab results
- Billing and insurance information
- Any information that identifies you as a patient
Certain records related to substance use disorder diagnosis, treatment, or referral for treatment receive additional protections under federal law (42 CFR Part 2).

How We May Use and Disclose Your Health Information

We may use and disclose your health information for the folowing purposes:
1. Treatment: To provide you with medical care and coordinate treatment with other healthcare professionals. Examples include:
  - Communicating with specialists
  - Reviewing lab results
  - Consulting with other providers involved in your care
2. Payment: To bill and receive payment from insurance companies or other responsible parties.
  - Submitting claims
  - Verifying insurance coverage
  - Collecting payment for services provided
3. Healthcare Operations: To operate and improve our practice. Examples include:
  - Quality improvement activities
  - Staff training
  - Licensing and compliance reviews
  - Medical audits
Additional Uses Allowed by Law

We may also disclose your information when required or permitted by law, such as:
- Public health reporting
- Preventing serious threats to health or safety
- Health oversight activities
- Legal proceedings or court orders
- Workers’ compensation claims
- Law enforcement requests permitted by law
Special Protections for Substance Use Disorder Records (42 CFR Part 2)

If you receive services related to substance use disorder treatment, federal law provides extra confidentiality protections. These records cannot be disclosed without your written consent, except in limited circumstances allowed by law.

Important Federal Notice

The confidentiality of substance use disorder patient records maintained by this program is proteted by federal law and regulations (42 CFR Part 2).

These records cannot be disclosed without the patient's written consent, unless otherwise permitted by federal law. Federal law prohibits further disclosure of this information unless the patient provides additional written consent or as otherwise permitted by law.

A general authorization for the release of medical information is NOT sufficient to release substance use disorder records.

Your Rights Regarding Your Health Information

You have the right to:
- Request a Copy of Your Records: You may request to review or obtain a copy of your medical records.
- Request Corrections: You may request corrections to your health record if you believe information is incorrect or incomplete.
- Request Confidential Communications: You may request that we communicate with you in a specific way (for example, at a different phone number or address).
- Request Restrictions: You may ask us to limit how we use or disclose your information.
- Receive an Accounting of Disclosures: You may request a list of certain disclosures of your health information made outside of treatment, payment, or healthcare operations.
- Receive a Paper Copy of This Notice: You may request a paper copy of this notice at any time.
Your Authorization

For uses or disclosures not describe in this notice, we will obtain your written authorization before sharing your information. You may revoke your authorization at any time in writing.

Complaints

If you have questions about this notice or your privacy rights, or you believe your privacy rights have been violated, you may file a complaint with HOAONC or HOAONC Privacy Officer. You will not be retaliated against for filing a complaint.

Contact Information

If you have any questions about this notice or privacy rights, please contact:

Privacy Officer
Hematology and Oncology Associates of Northern California
1631 Creekside Drive, #102 Folsom, CA 95630
916-250-0377
frontdesk@hoaonc.com

You may also file a complaint with:

U.S. Department of Health and Human Services
Office for Civil Rights

2000 Independence Avenue, S.W.

Washington, D.C. 20201

1-877-696-6775
https://www.hhs.gov/ocr

Changes to This Notice

We reserve the right to change this Notice and Hematology and Oncology Associates of Northern California privacy practices. We reserve the right to make the revised or changes Notice effective for protected health information we already have about you as well as any information we receive in the future. The new notice will be available upon request and on our website. This Notice will specify the effective date of this Notice.

Acknowledgment of Receipt of Notice

I acknowledge that a copy of the Notice of Privacy Practices is available for my review and a copy of this notice is also available upon request and that HOAONC reserves the right to change the term of this notice and that I will be notified of any amendments to the current notice at subsequent visits as needed. If I have any questions pertaining to the current notice, I can contact the Privacy Officer at HOAONC.
Patient or Legally Authorized Individual's Signature
Patient Name:
First and Last Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If Signed on Behalf of Patient, Relationship to Patient

CONSENT FOR ELECTRONIC MEDICATION HISTORY ACCESS
Patient Name:
First and Last Name
Patient DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
We are currently using electronic prescriptions and ask for you to grant us permission to access your medication history electronically.

Electronically accessing your medication history allows us to receive critically important information on your current and past prescriptions and to become better informed about potential medication issues. We can use this information to improve safety and quality.

By signing below, I give my consent for Hematology and Oncology Associates of Northern California to access my medication history electronically.
Consent for HOAONC to Fill Prescription(s)
I acknowledge that Hematology and Oncology Associates of Northern California has offered written prescription(s) that I may chose to have filled by HOAONC or by any pharmacy of my choice.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
If signed on behalf of patient, Print Name:
Relationship to Patient:

CONSENT FOR PATIENT PHOTOGRAPHY
I understand that my photograph is being taken for identification purposes only. I understand that Hematology and Oncology Associates of Northern California will retain ownership rights to these photographs and they will become a permanent part of my medical record for as long as that medical record exists. Images that identify me will be released only upon written authorization from me or my legal representation.
I hereby give my consent to be photographed:
Patient DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Signature:
Patient Name:
First and Last Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

PATIENT PORTAL: Ontada
User Electronic Mail Authorization Form
Ontada Health, the Patient Portal, offers convenient and secure access to your personal health record and a way to message your physician’s office. As the patient, you are in control of your Portal record: we will not activate your personal account unless you authorize us to do so.

Because personal identifying information and other information about your health and medical history is available via the Portal, it is very important that you keep your password private. Do not share your password with anyone or write it in a place easily accessible to others.

If you choose not to execute this User Electronic Mail Authorization Form, you will not be able to access the Portal. If you choose to submit this form, you understand you are consenting for us to email you a unique link that you will use to create a password in order to access the Portal. Please look for an email from Ontada three to five business days after submitting this form. For your protection, the link is designed to expire quickly if not used. If you should change your email address, please contact your physician’s office in order to provide your new email contact information so that you will continue to receive updates and other pertinent information about the Portal or your medical record. Please choose an email address that will not be subject to access by anyone you do not trust.

If you wish to discontinue utilizing the Portal, please contact your physician’s office.
I hereby opt into Ontada, the Patient Portal:
If you selected yes, please provide a secure email address below:
example@example.com
Patient DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Signature
Patient Name:
First and Last Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's Designee's Signature
Patient's Designee's Name:

CONSENT FOR RELEASE OF MEDICAL RECORDS
I hereby give my consent to release any or all requested records as listed below to Hematology and Oncology Associates of Northern California. Please select all the boxes.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Responsible Party Signature:
Relationship:

RELEASE OF INFORMATION

Please list any family members or friends whom you would like for Hematology and Oncology Associates of Northern California to release/discuss your medical information.

Rows	Name:	Contact info:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Patient Signature:
Patient Name:
First and Last Name
Patient DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

NOTICE TO PATIENT ABOUT CMS OPEN PAYMENTS DATABASE
The CMS Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payments and other payments of value worth over ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hosptials be made available to the public.

I have read and understand the above statement and accept the terms. A Duplicate of the statement is considered the same as the original.
Patient Signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Responsible Party Signature:
Relationship:

FINANICAL AGREEMENT
Hematology and Oncology Associates of Northern California is committed to providing the highest level of professional Medical care. For every commitment there is an obligation to provide quality care and service. Conversely, it is the Patients responsibility to meet their financial obligation.

This financial agreement should answer questions regarding patient and insurance responsibility for services rendered. Please read this agreement, ask us any questions you may have, and sign in the space provided. You will be given a copy of this agreement for your records.

I have received this financial policy, and understand that regardless of any insurance coverage I may have, I am responsible for payment of my account. I understand that delinquent accounts may be referred to a collection service. I also acknowledge that I have received a copy of this financial agreement for my records.

Insurance

Your insurance coverage is a contract between you and the insurance company, and it is your responsibility to know your insurance benefits. As a courtesy, we will bill both your primary and secondary insurance companies. We will submit your claims and assist you in any way we reasonably can to help get your claims processed. In order to do this, we must receive all the information necessary to bill. If the information is not supplied, you will be billed, and payment in full will be your responsibility and will be expected within 30 days of receipt of statement.

Medicare

We participate in Medicare. You are responsible for your co-insurance, any deductibles that have not yet been met, and services that are identified as patient responsibility on your Medicare Explanation of Benefits. We strive to inform our Medicare patients of services that will not be covered. We may ask you to sign an Advanced Beneficiary Notice, which lists out fee and notifies you of your financial responsibility for certain medical services.

Managed Care

Many patients are enrolled in Managed HealthCare. In order for us to obtain referrals and/or pre-authorizations for procedures, it is important that we have your current information. Depending on individual policies, your procedure may not be a covered benefit. It is your responsibility to check for optimal covered and policy limitations, and to obtain referrals as required by your insurance company. Please contact your insurance company with questions regarding your coverage.

Patient Responsibility for Payment

You are responsible for payments of any co-payment, co-insurance, deductible or service not covered by your insurance, handing, collection or attorney fees. If you do not have insurance, you are responsible for payment of all services. Co-payments are due at the time of your service. Patient due balances noted on your monthly statement are due within 30 days of receipt. We will bill appropriate insurance if all required information is provided.

Deposits

New patients without insurance, or if insurance co-payment and coverage cannot be verified, are required to a deposit on or before the first date of service. If insurance payments results in a credit balance, it will be refunded to you within 30 days.

Payment Options

We understand that financial circumstances vary from patient to patient. If you are unable to pay your patient due balance in full, you must call our business office at 916-250-0166 to make payment arrangements. We offer uninsured patients a 10% discount for payment of office visit by cash, check, or credit card received on the date of service. Discount does not apply to lab or supply charges. Accounts with a patient due balance outstanding over 30 days will be charged a finance charge.

Non-Payment

Failure to pay will result in your account being referred to a collection agency, which may affect your credit. You must contact out collection analyst to discuss payment arrangements. If it becomes necessary to send my account to a collection service, I agree to pay for all costs and expenses, including reasonable attorney fees.
Patient Signature:
Patient Name:
First and Last Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

AI Scribe Consent Form

Hematology and Oncology Associates of Northern California uses AI-assisted scribe technology during some patient visits. This tool listens to your appointment and helps generate clinical documentation, allowing your physician to focus more attention on you and less on note-taking.
How it works
- The AI scribe records and transcribes conversation during your visit to assist with documentation.
- Your physician and care team review all AI-generated notes for accuracy before they are added to your medical record.
- Recording and transcripts are handled securley and are used only for the purpose of clinical documentation.
- You may decline the use of AI scribe technology at any time without any effect on the care you receive.
Patient Acknowledgment

Please initial one option below:

___ I consent to the use of AI Scribe technology during my visit(s) at this practice.

___ I decline the use of AI scribe technology. My care team will document my visit using standard note-taking methods instead.

I understand that I may change my decision at any time by informing my care team, and that this choice will not affect the quality of care I receive.
Consent Initials
Decline Initials
Name

First NameLast Name
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

CONSENT FORMS

SUMMARY NOTICE OF HIPAA PRIVACY PRACTICES

CONSENT FOR ELECTRONIC MEDICATION HISTORY ACCESS

Consent for HOAONC to Fill Prescription(s)

CONSENT FOR PATIENT PHOTOGRAPHY

PATIENT PORTAL: Ontada

User Electronic Mail Authorization Form

CONSENT FOR RELEASE OF MEDICAL RECORDS

RELEASE OF INFORMATION

ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBILITIES

NOTICE TO PATIENT ABOUT CMS OPEN PAYMENTS DATABASE

FINANICAL AGREEMENT

AI Scribe Consent Form