PATIENT PORTAL - Regional Cancer Care Associates LLC
Transcription
PATIENT PORTAL - Regional Cancer Care Associates LLC
RANDI J. KATZ, D.O. RAGHU K. KUNAMNENI, M.D. KENNETH D. NAHUM, D.O., F.A.C.P. MONIR SOLIMAN, M.D. ETHAN WASSERMAN, M.D. PATIENT PORTAL Dear Patients, We have been taking steps to get our patient portal open for you to view. Currently, we are communicating with patients regarding their PT/INR results, as well as their iron results. All patients are also able to view their blood work results through the portal. If you are not registered for the portal, please let us know and we will be happy to assist you. As of Monday, March 23, 2015, we are opening the patient portal for you to communicate with us regarding your appointments; and as of April 1, 2015, you will be able to communicate with the office regarding medication refills. Please bear with us as we make this transition. Please note: We will no longer be able to draw cholesterol levels during your lab appointment Insurance will not cover this test. This ¡s also the reason that we cannot draw blood work ordered by other physicians. Thank you for your understanding. Dr. Nahum Dr. Katz Dr. Kunamneni Dr. Wasserman 4632 Route 9 South, Howell. NJ 07731 • Phone: (732) 367-1535 • Fax: (732) 367-9514 1540 Route 138, Building 2, Wall, NJ 07719 • Phone: (732) 280-9685 • Fax: (732) 367-9514 9 Hospital Drive, Suite A17, Toms River, NJ 08755 • Phone: (732) 279-6401 • Fax: (732) 367-9514 RANDI J. KATZ, D.O. RAGHU K. KUNAMNENI, M.D. KENNETH D. NAHUM, D.O., F.A.C.P. MONIR SOLIMAN, M.D. ETHAN WASSERMAN, M.D. Date:__/__/____ Last Name: First Name: Address: MI: Phone: Primary Care Physician: Work Phone: Ext: Social Security#: Referred by: (street name & number) Gender: M F (city) (state/zip) Employer: DOB:__/__/__ Occupation: Marital Status: S M D W Pharmacy: INSURANCE INFORMATION Primary Insurance: E-mail address: Secondary Insurance: ID#: ID#: Group #: Group #: Name of Insured: Name of Insured: Insured DOB:__/__/____ Insured DOB:__/__/____ Insured Social Security #: Insured Social Security #: EMERGENCY CONTACT: Name: Phone #: Address: Relationship to Patient: City: State: Zip: GUARANTOR (PERSON RESPONSIBLE FOR BILL) INFORMATION: Last Name: First Name: MI: Relationship to Patient: I understand that I am responsible for all financial obligations of health services and for reimbursement and payment of claims from my insurance company. If for any reason the account should become delinquent, I agree to pay for all billing charges, interest charges, collection costs and reasonable legal fees. Date:__/__/____ Parent or Guardian Name: Age: DOB__/__/____ DOB__/__/____ MEDICAL HISTORY Allergies to medication? ( ) Yes ( ) No If “Yes”, list medications: Allergies to: IODINE SULFA Do you currently have problems in any of the following areas? Anemia (low, weak blood) Arthritis / Rheumatism Asthma Bleeding Tendency / Unusual Bruising Bowel Disorders / Colitis / Crohns Cancer / Tumors Diabetes Gallbladder Trouble / Gallstones High Blood Pressure / Hypertension Heart Disease Hepatitis Skin (Warts, Skin Cancer, Unusual Moles) Neurological Problems Respiratory (Recurrent Pneumonia, Bronchitis, Emphysema) If “YES” to any of the above, please provide details here: SHELLFISH Yes No FAMILY HISTORY: (If “Yes”, Indicate relationship to pt.): M=mother,F=father,S=sibling,GP=grandparent YES NO REL. YES NO REL. DISEASE DISEASE High Blood Pressure Heart Disease Cancer Gastrointestinal Problems ( ( ( ( ) ) ) ) ( ( ( ( ) ) ) ) ( ( ( ( ) ) ) ) ( ( ( ( ) ) ) ) Anemia Bleeding Disorder Diabetes ( ) ( ) ( ) ( ) ( ) ( ) SOCIAL HISTORY: Do you drink alcohol? Do you smoke? Cultural / language barriers? Advanced directives? Physician’s signature: ( ) ( ) ( ) occasional ( ½ pack-less/day ) 1/day ( ) ( ) 2-3/day 1pack/day ( ) 4+/day ( ) 1+pack/day Date__/__/____ RANDI J. KATZ, D.O. RAGHU K. KUNAMNENI, M.D. KENNETH D. NAHUM, D.O., F.A.C.P. MONIR SOLIMAN, M.D. ETHAN WASSERMAN, M.D. ASSIGNMENT AGREEMENT Insured’s Name: Patient’s Name: Insurance: Policy Number: “I request that payment of authorized Medicare and/or my insurance benefits be made on my behalf to Dr. Nahum, D.O. for any services furnished to me or by my physician.” “I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents or my insurance company any information needed to determine these benefits or the benefits payable for related services.” A photocopy of this agreement shall be deemed as valid as the original. “I understand I am still responsible for non-covered charges, co-pays and deductibles.” Insured Signature Date SECONDARY INSURANCE Insured’s Name: Patient’s Name: Insurance: Policy Number: “I request that payment of authorized Medigap benefits be made either to me or on my behalf to the provider of service and (or) supplier for any services furnished to me by that the provider of service and (or) supplier. I authorize any holder of Medicare information about me to release to (Name of 2nd Ins.)______________ any information needed to determine these benefits payable for related services.” Insured Signature Date RANDI J. KATZ, D.O. RAGHU K. KUNAMNENI, M.D. KENNETH D. NAHUM, D.O., F.A.C.P. MONIR SOLIMAN, M.D. ETHAN WASSERMAN, M.D. ATTENTION PATIENTS PLEASE BE ADVISED THAT OUR OFFICE DOES SUBMIT YOUR ENCOUNTER VISITS WITH THE PHYSICIANS TO YOUR INSURANCE COMPANY. WE RELY ON OUR PATIENTS TO SUPPLY US WITH THE CORRECT INSURANCE INFORMATION. WE MUST MAKE OUR PATIENTS AWARE THAT IF YOU SUPPLY OUR OFFICE WITH THE WRONG INSURANCE INFORMATION AT THE TIME OF SERVICE OR NEGLECT TO TELL US OF AN INSURANCE CHANGE, AND THE CLAIM IS FILED, ONCE WE ARE GIVEN THE CORRECT INSURANCE INFORMATION THE CLAIM MAY BE DENIED DUE TO UNTIMELY FILING. IF THIS IS THE CASE, YOU MAY BE RESPONSIBLE FOR YOUR BALANCE IN FULL. IT IS YOUR RESPONSIBILITY TO SUPPLY OUR OFFICE WITH ALL THE CORRECT INSURANCE INFORMATION AT THE TIME OF THE VISIT. PLEASE VERIFY WITH TITE RECEPTIONIST. THAT WE HAVE ALL OF YOUR INFORMATION CORRECT. I HAVE READ THE ABOVE NOTICE AND I AM AWARE THAT IF I DO NOT SUPPLY THIS OFFICE WITH MY CORRECT BILLING INFORMATION, I MAY BE RESPONSIBLE FOR MY BALANCE IN FULL. PATIENT SIGNATURE DATE 4632 Route 9 South, Howell. NJ 07731 • Phone: (732) 367-1535 • Fax: (732) 367-9514 1540 Route 138, Building 2, Wall, NJ 07719 • Phone: (732) 280-9685 • Fax: (732) 367-9514 9 Hospital Drive, Suite A17, Toms River, NJ 08755 • Phone: (732) 279-6401 • Fax: (732) 367-9514 RANDI J. KATZ, D.O. RAGHU K. KUNAMNENI, M.D. KENNETH D. NAHUM, D.O., F.A.C.P. MONIR SOLIMAN, M.D. ETHAN WASSERMAN, M.D. Patient Name: Date: Please list all of your current prescription and over the counter medications. Drug Allergies: Current Medication 1. 2. 3. 4. 5. 6. 7. 8 9. 10. 11. 12. 13. 14. Strength Dose Family History Questionnaire for Hereditary Cancer Syndromes Patient Name: Phone: Date of Birth: Gender: M / F Ethnicity: Email: Date Completed: www.genedx.com/MyCancerHistory Please complete the below questionnaire to assist your healthcare provider in determining if your personal or family history may be placing you or other family members at increased risk to develop cancer, and if you may be eligible for genetic testing (which is often done via a blood test). Tips: • Each row should be completed independently • Affected relatives on your mother’s side of the family should be listed in the pink boxes and affected relatives on your father’s side of the family should be listed in the blue boxes • Age at diagnosis is the age at which the cancer was diagnosed • Other friends and family can assess their cancer risk by going to www.genedx.com/MyCancerHistory where they can complete this same form and share it with a healthcare professional. Past genetic testing for cancer: Self Relative Result: You Breast and Ovarian Cancer Immediate Blood Relatives Age at Diagnosis Parents, Siblings or Children Age at Diagnosis 45 Mother Sister 49 36 Extended Blood Relatives (Aunts, Uncles, Grandparents, etc.) Mother’s Side Age at Diagnosis Father’s Side Age at Diagnosis Example: Woman with Breast Cancer at age ≤50 Maternal Aunt 46 Paternal First Cousin 50 Woman with Breast Cancer at age ≤50 Woman with Breast Cancer >50 “Triple Negative” Breast Cancer (Estrogen Receptor (ER) negative, Progesterone Receptor (PR) negative, HER2neu negative ) Ovarian, fallopian tube, or primary peritoneal cancer A woman who has been diagnosed with both breast and ovarian cancer in her lifetime (two separate cancers) Male breast cancer Bilateral breast cancer (cancer in both breasts) or two breast primaries Please specify Ashkenazi (Eastern/Central European) Jewish ancestry with breast or ovarian cancer Pancreatic or Prostate Cancer Please specify Colorectal and Endometrial (Uterine) Cancer Age at Diagnosis Siblings or Children Age at Diagnosis Mother’s Side Age at Diagnosis Father’s Side Colorectal cancer or several pre-cancerous polyps (adenomas) at an age ≤50 An individual who has been diagnosed with two or more colon cancers (not reoccurrences, but two separate primary cancers) A woman who has been diagnosed with endometrial (uterine) cancer at age ≤50 OR both colorectal and endometrial (uterine) cancer Please specify 10 or more total pre-cancerous polyps (adenomas) in a person’s lifetime Relatives with any of the below related cancers* Please specify * Related cancers include colon, endometrial (uterine), ovarian, stomach, pancreas, ureter, kidney, biliary tract, brain, small intestine, and sebaceous gland tumors/cancers Age at Diagnosis NCCN Genetic Testing Criteria for Hereditary Breast and Ovarian Cancer Syndrome Family history of a known BRCA1 or BRCA2 mutation Personal history of breast cancer diagnosed at age 45 or younger Personal history of breast cancer diagnosed at age 50 or younger with one of the following: • ≥1 close blood relative(s) with breast cancer at any age • An unknown or limited family history • Two breast primaries, the first of which was diagnosed at age 50 or younger Personal history of a triple negative breast cancer diagnosed at age 60 or younger Personal history of epithelial ovarian, fallopian tube, or primary peritoneal cancer at any age Personal history of male breast cancer at any age Personal history of breast cancer at any age with one or more of the following: • ≥1 close blood relative(s) with breast cancer diagnosed at age 50 or younger • ≥2 close blood relatives with breast cancer at any age • ≥1 close blood relative(s) with epithelial ovarian/fallopian tube/primary peritoneal cancer • Close male blood relative with breast cancer • ≥2 close blood relatives with pancreatic cancer and/or prostate cancer (Gleason score ≥7) at any age • For an individual of ethnicity associated with higher mutation frequency (e.g., Ashkenazi Jewish) no additional family history may be required* Personal history of pancreatic cancer or prostate cancer (Gleason score ≥7) at any age with ≥2 close blood relatives with breast and/or ovarian and/or pancreatic and/or prostate cancer (Gleason score ≥7) at any age • For pancreatic cancer, if Ashkenazi Jewish ancestry, only one additional affected relative is needed Unaffected patient with a first or second-degree relative who meets any of the above criteria • Testing unaffected individuals should only be considered when an appropriate affected family member is unavailable for testing *Testing for Ashkenazi Jewish founder-specific mutation(s) should be performed first. Full sequencing may be considered if ancestry also includes non-Ashkenazi Jewish relatives or other criteria are met. NCCN Testing Criteria For Lynch Syndrome (also known as HNPCC) and Polyposis Syndromes Criteria for Lynch Syndrome genetic testing Family history of a known Lynch syndrome mutation (MLH1, MSH2, MSH6, PMS2, EPCAM) Patient has a cancer on the Lynch syndrome tumor spectrum that demonstrates microsatellite instability (MSI-H) or absence of a mismatch repair protein via immunohistochemistry (IHC) Patient diagnosed with endometrial cancer at age 50 or younger Meets Revised Bethesda Guidelines: • Patient has a personal history of colorectal cancer AND meets one of the following: • Patient diagnosed at age 50 or younger • Presence of synchronous or metachronous Lynch syndrome-associated cancers, regardless of age • Patient diagnosed at age 60 or younger with a colorectal cancer that demonstrates MSI-high histology (tumor-infiltrating lymphocytes, Crohn’s-like lymphocytic reaction, mucinous/signet-ring differentiation, or medullary growth pattern) • One or more first-degree relatives with a Lynch syndrome-associated cancer, with one of the cancers being diagnosed at age 50 or younger • Two or more first- or second-degree relatives with Lynch syndrome-associated cancers, regardless of age Meets Amsterdam Criteria: • Patient and at least two close relatives who all have or have had a cancer associated with Lynch syndrome AND all of the following criteria must be met: • One must be a first-degree relative of the other two; • At least two successive generations must be affected; • At least one of the cancers should be diagnosed at age 50 or younger; • Familial adenomatous polyposis (FAP) should be excluded Unaffected patient with a close relative who meets any of the above criteria • Testing unaffected individuals when no affected family member is available should be considered; significant limitations of interpreting test results should be discussed Criteria for Adenomatous Polyposis (APC and MUTYH) genetic testing Family history of a known APC mutation or two (biallelic) MUTYH mutations Personal history of a total of >10 adenomas Personal history of a desmoid tumor Other Polyposis Syndrome Genetic Testing Criteria Personal or family history of multiple GI hamartomatous polyps or serrated polyps Guidelines are current as of October, 2014. Please visit www.nccn.org for the most current guidelines. 207 Perry Parkway Gaithersburg, MD 20877 T 1 888 729 1206 • F 1 301 710 6594 E [email protected] • www.genedx.com © 2014 GeneDx. All rights reserved. 91855 10/2014 NOTICE OF PRIVACY PRACTICES REGIONAL CANCER CARE ASSOCIATES LLC 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. This Notice of Privacy Practices (Notice) is provided to you by Regional Cancer Care Associates LLC (RCCA) pursuant to the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, as amended (HIPAA). The Notice describes how RCCA may use and disclose your Protected Health Information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your Protected Health Information. "Protected Health Information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition; provision of health care services to you; or the past, present or future payment for the provision of health care services to you. Uses and Disclosures of Protected Health Information Your Protected Health Information may be used and disclosed by RCCA and others outside of our offices that are involved in your care and treatment for the purposes of providing health care services to you, to pay your health care bills, to support the operation of the physicians' practice, and any other uses required or permitted by law. Treatment RCCA will use and disclose your Protected Health Information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, RCCA may disclose your Protected Health Information as necessary, to a home health agency that provides care to you; or your Protected Health Information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, RCCA may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. RCCA personnel may also call you by name in the waiting room when your physician is ready to see you. Additionally, RCCA may use or disclose your Protected Health Information, as necessary, to contact you to remind you of your appointment or to provide you with information about alternative treatments or other health care services we provide. If you request that RCCA not make such contact with you, RCCA will observe your wishes. 1 Payment Your Protected Health Information will be used, as necessary, to obtain payment for your health care services. For example, obtaining approval for a procedure requiring prior authorization by your health plan or obtaining approval for a hospital stay may require that your relevant Protected Health Information be disclosed to the health plan to obtain approval for the procedure or hospital admission. Healthcare Operations RCCA may use or disclosed, as necessary, your Protected Health Information in order to support the business activities of the medical practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical and heath care students, licensing, and conducting or arranging for other business activities. For example, RCCA may disclose your Protected Health Information to medical school students that see patients at our offices. There are some services that RCCA may provide through agreements with business associates. When these services are contracted, RCCA may disclose your Protected Health Information to our business associate and bill you or your health plan for the services rendered. To protect you Protected Health Information, however, RCCA requires the business associate to appropriately safeguard your information. Other Uses and Disclosures That Do Not Require Prior Authorization Required By Law: RCCA may use or disclose your Protected Health Information as required by law, including, but not limited to, reporting of communicable diseases, incidence of cancer, burns, seizures, gun shots, abuse, organ donations, product recalls, product failures, births/deaths, birth defects and other required uses and disclosures. Public Health Purposes: RCCA may disclose Protected Health Information to local, state or federal public health authorities, as authorized or required by law, to prevent or control disease, injury or disability; report child abuse or neglect; report domestic violence; report Food and Drug Administration problems with products and reaction to medications; and report disease or infection exposure. Health Oversight Activities: RCCA may use or disclose Protected Health Information to health agencies during the course of audits, investigations, surveys, accreditation, certification and other proceedings necessary for oversight of (1) the health care system, (2) government benefit programs for which health information is relevant to beneficiary eligibility, (3) entities subject to government regulatory programs for which health information is necessary for determining compliance with program standards; and (3) entities subject to civil rights laws for which health information is necessary for determining compliance. Judicial and Administrative Proceedings: RCCA may use or disclose Protected Health Information in the course of a judicial or administrative proceeding. However, in certain instances you may be made aware of the use or disclosure of your Protected Health Information prior to its release. 2 Law Enforcement Purposes: RCCA may use or disclose Protected Health Information to law enforcement officials to identify or locate a suspect, fugitive, material witness, or missing person, or, in some cases, to comply with a court order or subpoena and for other law enforcement purposes. Coroners or Funeral Directors: RCCA may disclose Protected Health Information to coroners or funeral directors consistent with applicable law to carry out their duties. Organ Procurement Organizations: Consistent with applicable law, RCCA may disclose Protected Health Information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant. Research: RCCA may disclose information to researchers when their research has been approved by an Institutional Review Board (IRB). IRBs review research proposals and established protocols to ensure the privacy of your Protected Health Information. Public Safety: RCCA may use or disclose Protected Health Information in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public. Specialized Government Functions: RCCA may use or disclose Protected Health Information for military or national security purposes. Protected Health Information of patients who are Armed Services personnel may be used or disclosed: (1) for activities deemed necessary by the appropriate military authorities; (2) for the purposes of a determination by the Department of Veteran Affairs of your eligibility for benefits; or (3) to a foreign military authority if you are member of that foreign military service. RCCA may use or disclose Protected Health Information to authorized federal officials for national security and intelligence activities. Workers’ Compensation: RCCA may disclose Protected Health Information to the extent authorized and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs established by law. Correctional Institution: RCCA may disclose Protected Health Information to corrections officials or agents necessary for the health or safety of inmate patients or other individuals. Family and Friends: Unless you indicate otherwise, RCCA may release your Protected Health Information to a family member or friend identified by you, that is helping you pay for your health care or who assists in taking care of you. In addition, RCCA may use or disclose information about your location and general condition to notify or assist in notifying a family member, personal representative, or another person responsible for your care. Fundraising: RCCA may use or disclose Protected Health Information for the purposes of communicating with you as part of RCCA’s or RCCA affiliates’ fundraising activities. You may optout of receiving such fundraising communications. RCCA may not condition treatment or payment on your choice regarding fundraising communications. 3 Health Information Exchange: RCCA may use or disclose Protected Health Information electronically for treatment, payment and health care operation purposes through its participation in a health information exchange with other health care providers. You may opt-out of the health information exchange. If so, your Protected Health Information will continue to be used in accordance with this Notice and the law; however, your Protected Health Information will not be made electronically available through the health information exchange. Required Uses and Disclosures Under the law, RCCA must make disclosures to you, upon your request, and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of HIPAA. De-Identified Information Any information RCCA provides to a third party other than to our business associates or other health care providers with a treatment relationship to you will be de-identified or stripped of any and all personal data which could be used to identify a specific individual. Written Authorization Except for the purposes described above, RCCA will only use or disclose Protected Health Information with your express written authorization and you may revoke that authorization at any time in writing. In addition, prior to most uses or disclosures of psychotherapy notes, uses and disclosures of Protected Health Information for marketing purposes, or disclosures that constitute sale of Protected Health Information, RCCA is required to obtain your authorization. Please note, however that revocations will apply only to future uses and disclosures of your Protected Health Information. Your Rights With Respect To Your Protected Health Information With respect to your Protected Health Information, you have the right to the following from RCCA: •Restrict Use Or Disclosure - You may ask RCCA not to use or disclose any part of your Protected Health Information for the purposes of treatment, payment or health care operations. You may request that certain uses or disclosures of your Protected Health Information be restricted. To do so, you must provide the request in writing using the Request for Restriction on Use or Disclosure form available from our offices. RCCA will determine if the information constitutes required information to carry out treatment, payment or health care operations. If, in our sole opinion, your request does not involve information that is required by RCCA to carry out treatment, payment or health care operations, RCCA will accept your request for restrictions and will notify you if your request will be honored within 30 days or as required by law. Please note, however, that your physician is not required to agree to a restriction that you may request, except in instances where you request that RCCA restrict use and disclosure of your Protected Health Information to a health plan for payment or health care operation 4 purposes and such information pertains solely to a health care item or service for which you paid “out of pocket” in full. Otherwise, if your physician believes it is in your best interest to permit use and disclosure of your Protected Health Information, your Protected Health Information will not be restricted. You then have the right to use another health care professional. •Confidential Communication Of Protected Health Information - You may request that RCCA communicate your Protected Health Information to you by different means or to different places. For example, you may request to receive information about your health status in a special, private room or through correspondence sent to a private address. Generally, RCCA communicates with patients via telephone and US mail service. •Inspection And Copying - You may request a report containing your Protected Health Information that has been collected by RCCA for you to inspect or copy. Such requests will be honored within 30 days or as required by law. You will be notified in writing of RCCA’s receipt of the request and the date upon which the information will be made available to you. •Amendment Or Correction - You may request that RCCA amend or correct your Protected Health Information that has been collected by RCCA. Upon agreement, requests to amend Protected Health Information will be honored within 60 days or as required by law. However, RCCA may deny a requested amendment if it determines that the information is complete, accurate, and on limited grounds. If denied, RCCA will provide the individual with an opportunity to file a statement of disagreement and RCCA will provide documentation of the dispute. You will be notified in writing of the action taken by RCCA. •Accounting Of Disclosures - You may request that RCCA supply you with a listing of the disclosures of your Protected Health Information which have been made by RCCA, except disclosures , among others, made to you; upon your authorization; for treatment, payment or health care operations; and for certain government functions. Such requests will be honored within 60 days or as required by law. You will be notified in writing of the date on which the accounting will be made available to you. Paper Notice Upon your request, you may receive a paper copy of this Notice from RCCA, even if you have previously agreed to receive the Notice electronically. Copies of the Notice are available at the registration desks in the offices of RCCA. RCCA’s Duties To You Generally RCCA is required by law to maintain the privacy of Protected Health Information; to provide you with notice of our legal duties and privacy practices with respect to Protected Health Information; and to notify you following a breach of unsecured Protected Health Information. Additionally, RCCA must follow the privacy practices described in this Notice. 5 Amendments RCCA reserves the right to change the privacy practices described in this Notice at any time. Changes to the privacy practices will apply to all Protected Health Information RCCA maintains, even Protected Health Information created prior to the changes in the revised Notice. If RCCA makes changes to the Notice, RCCA will immediately display the revised Notice at our offices and on our website at regionalcancercare.org. RCCA will also provide you with a copy of the Notice upon request. Complaints If you believe that your privacy rights have been violated, you may send questions or complaints to us and/or the Secretary of the Department of Health and Human Services. RCCA will not retaliate against you for filing such a complaint. If you have any complaints or objections related to the matters discussed in this Notice, you may direct your communication to the Privacy Officer at: Regional Cancer Care Associates LLC 100 First Street, Ste. 301 Hackensack, NJ 07601 Attn: Privacy Officer 201.996.4320 Effective Date This Notice is effective as September 23, 2013, based on revisions to privacy practices originally implemented April 14, 2003. Your signature below is only acknowledgement that you have received a copy of this Notice: ________________________________ Printed Name ________________________________ Signature Date:________________________________ 6