Xxxx and Release Medical Information to Insurance Company Sample Clauses

Xxxx and Release Medical Information to Insurance Company. I herby authorize Gladstone Psychiatry & Wellness, LLC to submit claims to my insurance company. I hereby request and authorize that payment of medical benefits be paid directly to Gladstone Psychiatry & wellness, LLC for services provided. I herby accept full and complete financial responsibility for all charges due for medical services rendered to me. I agree to pay any and all charges that are not covered by my insurance company, including insurance copayments, deductibles, and co-insurance, that may be required under the terms of my medical insurance policies. I agree to pay any and all charges that are considered a “non-covered” service under the terms of my medical insurance plan. I herby authorize Gladstone Psychiatry & Wellness, LLC to disclose all or any part of the medical record of the patient named on this consent to my insurance company consistent with Federal HIPAA regulations. This authorization is given with full knowledge and understanding that such disclosure may contain information which may result in a valid denial of insurance benefits, or which otherwise may not serve my interests. Telemedicine & Online Counseling Agreement Telemedicine and online counseling are useful supplements to in person mental health treatment services for some patients. Many patients find it convenient and easy to access. This is best used in conjuncture with in-person mental health treatment services. The following document outlines the potential limitations and risk associated with Telemedicine and online counseling. Licensing and State Requirements States vary on the laws around telemedicine and online counseling. It is the patient’s duty to inform the clinician if they travel out of the state that they presented at the time of intake. The clinician will inform the patient if they are able to provide the service in the state they are located. *I agree to inform the counselor if I am no longer in the state presented at time of intake Confidentiality For telemedicine and online counseling sessions, service is delivered using a secure site such as through the electronic medical record system (Xxxxxx) or Zoom. The patient is provided with instructions and a link in order to login. Other means of communication, such as the telephone, may be used if agreed upon by both the clinician and the patient. There are potential risks to confidentiality when using telemedicine and online counseling, such as data hacks, password protection, forgetting to log off, a patient ...
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  • Customer Information and Release Authorization Throughout this Agreement, you authorize Clearview Energy or its agents to obtain and review information from credit-reporting agencies regarding your credit history and information from the Utility relating to you and your account that includes, but is not limited to: account name and number; billing history; payment history; rate classification; historical and future electricity usage; meter readings; and characteristics of electricity service. Clearview Energy will not provide or sell such information to any other party without your consent unless required to do so by law, or it is necessary to enforce the terms of this Agreement. Clearview Energy reserves the right to reject your enrollment, or terminate this Agreement, in the event you rescind these authorizations.

  • Right to Receive and Release Needed Information Certain facts are needed to apply these COB rules. The Plan has the right to de­ cide which facts it needs. It may get needed facts from or give them to any other organization or person. The Plan need not tell, or get the consent of, any person to do this. Each person claiming benefits under this Benefit Program must give the Plan any facts it needs to pay the Claim. FACILITY OF PAYMENT A payment made under another Benefit Program may include an amount that should have been paid under this Benefit Program. If it does, the Plan may pay that amount to the organization that made the payment under the other Benefit Program. That amount will then be treated as though it were a benefit paid under this Benefit Program. The Plan will not have to pay that amount again. The term “payment made” includes providing benefits in the form of services, in which case “payment made” means reasonable cash value of the benefits provided in the form of services. RIGHT OF RECOVERY If the amount of payments made by the Plan is more than it should have paid un­ der this COB provision, it may recover the excess from one or more of:

  • Confidentiality and Safeguarding of University Records; Press Releases; Public Information Under this Agreement, Contractor may (1) create, (2) receive from or on behalf of University, or (3) have access to, records or record systems (collectively, University Records). Among other things, University Records may contain social security numbers, credit card numbers, or data protected or made confidential or sensitive by Applicable Laws. [Option (Include if University Records are subject to FERPA.): Additional mandatory confidentiality and security compliance requirements with respect to University Records subject to the Family Educational Rights and Privacy Act, 20 United States Code (USC) §1232g (FERPA) are addressed in Section 12.41.] [Option (Include if University is a HIPAA Covered Entity and University Records are subject to HIPAA.): Additional mandatory confidentiality and security compliance requirements with respect to University Records subject to the Health Insurance Portability and Accountability Act and 45 Code of Federal Regulations (CFR) Part 160 and subparts A and E of Part 164 (collectively, HIPAA) are addressed in Section 12.26.] Contractor represents, warrants, and agrees that it will: (1) hold University Records in strict confidence and will not use or disclose University Records except as (a) permitted or required by this Agreement, (b) required by Applicable Laws, or (c) otherwise authorized by University in writing; (2) safeguard University Records according to reasonable administrative, physical and technical standards (such as standards established by the National Institute of Standards and Technology and the Center for Internet Security [Option (Include if Section 12.39 related to Payment Card Industry Data Security Standards is not include in this Agreement.):, as well as the Payment Card Industry Data Security Standards]) that are no less rigorous than the standards by which Contractor protects its own confidential information; (3) continually monitor its operations and take any action necessary to assure that University Records are safeguarded and the confidentiality of University Records is maintained in accordance with all Applicable Laws and the terms of this Agreement; and (4) comply with University Rules regarding access to and use of University’s computer systems, including UTS165 at xxxx://xxx.xxxxxxxx.xxx/board-of-regents/policy-library/policies/uts165-information-resources-use-and-security-policy. At the request of University, Contractor agrees to provide University with a written summary of the procedures Contractor uses to safeguard and maintain the confidentiality of University Records.

  • Insurance and Fingerprint Requirements Information Insurance If applicable and your staff will be on TIPS member premises for delivery, training or installation etc. and/or with an automobile, you must carry automobile insurance as required by law. You may be asked to provide proof of insurance. Fingerprint It is possible that a vendor may be subject to Chapter 22 of the Texas Education Code. The Texas Education Code, Chapter 22, Section 22.0834. Statutory language may be found at: xxxx://xxx.xxxxxxxx.xxxxx.xxxxx.xx.xx/ If the vendor has staff that meet both of these criterion: (1) will have continuing duties related to the contracted services; and (2) has or will have direct contact with students Then you have ”covered” employees for purposes of completing the attached form. TIPS recommends all vendors consult their legal counsel for guidance in compliance with this law. If you have questions on how to comply, see below. If you have questions on compliance with this code section, contact the Texas Department of Public Safety Non-Criminal Justice Unit, Access and Dissemination Bureau, FAST-FACT at XXXX@xxxxx.xxxxx.xx.xx and you should send an email identifying you as a contractor to a Texas Independent School District or ESC Region 8 and TIPS. Texas DPS phone number is (000) 000-0000. See form in the next attribute to complete entitled: Texas Education Code Chapter 22 Contractor Certification for Contractor Employees

  • Exclusions from Confidential Information Receiving Party's obligations under this Agreement do not extend to information that is: (a) publicly known at the time of disclosure or subsequently becomes publicly known through no fault of the Receiving Party; (b) discovered or created by the Receiving Party before disclosure by Disclosing Party; (c) learned by the Receiving Party through legitimate means other than from the Disclosing Party or Disclosing Party's representatives; or (d) is disclosed by Receiving Party with Disclosing Party's prior written approval.

  • INFORMATION TO EMPLOYEES In the initial correspondence with an individual regarding potential employment in the bargaining unit, the appropriate department shall include a one-page statement about the Union, prepared by the Union at its own expense, provided that the statement is first forwarded to the Executive Director, Human Resources and is not determined to be factually incorrect or inflammatory. If the Executive Director, Human Resources does not forward any suggested changes within two weeks of receiving the statement, the information shall be presumed to be acceptable.

  • Release of Confidential Information No Party shall release or disclose Confidential Information to any other person, except to its Affiliates (limited by FERC Standards of Conduct requirements), subcontractors, employees, consultants, or to parties who may be considering providing financing to or equity participation with Developer, or to potential purchasers or assignees of a Party, on a need-to-know basis in connection with this Agreement, unless such person has first been advised of the confidentiality provisions of this Article 22 and has agreed to comply with such provisions. Notwithstanding the foregoing, a Party providing Confidential Information to any person shall remain primarily responsible for any release of Confidential Information in contravention of this Article 22.

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  • Contact Information for Privacy and Security Officers and Reports 2.1 Business Associate shall provide, within ten (10) days of the execution of this Agreement, written notice to the Contract or Grant manager the names and contact information of both the HIPAA Privacy Officer and HIPAA Security Officer of the Business Associate. This information must be updated by Business Associate any time these contacts change.

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