Orlando City Health New Patient

HIPAA NOTICE OF PRIVACY PRACTICES Effective Date: May 1, 2022 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The terms of this Notice of Privacy Practices (“Notice”) apply to Orlando City Health and Wellness, its affiliates and its employees. Orlando City Health and Wellness will share protected health information of patients as necessary to carry out treatment, payment, and health care operations as permitted by law. We are required by law to maintain the privacy of our patients' protected health information and to provide patients with notice of our legal duties and privacy practices with respect to protected health information. We are required to abide by the terms of this Notice for as long as it remains in effect. We reserve the right to change the terms of this Notice as necessary and to make a new notice of privacy practices effective for all protected health information maintained by Orlando City Health and Wellness. We are required to notify you in the event of a breach of your unsecured protected health information. We are also required to inform you that there may be a provision of state law that relates to the privacy of your health information that may be more stringent than a standard or requirement under the Federal Health Insurance Portability and Accountability Act (“HIPAA”). A copy of any revised Notice of Privacy Practices or information pertaining to a specific State law may be obtained by mailing a request to the Privacy Officer at the address below.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION: Authorization and Consent: Except as outlined below, we will not use or disclose your protected health information for any purpose other than treatment, payment or health care operations unless you have signed a form authorizing such use or disclosure. You have the right to revoke such authorization in writing, with such revocation being effective once we actually receive the writing; however, such revocation shall not be effective to the extent that we have taken any action in reliance on the authorization, or if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself. Uses and Disclosures for Treatment: We will make uses and disclosures of your protected health information as necessary for your treatment. Doctors and nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to your course of treatment that may include procedures, medications, tests, medical history, etc. Uses and Disclosures for Payment: We will make uses and disclosures of your protected health information as necessary for payment purposes. During the normal course of business operations, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you. We may also use your information to prepare a bill to send to you or to the person responsible for your payment. Uses and Disclosures for Health Care Operations: We will make uses and disclosures of your protected health information as necessary, and as permitted by law, for our health care operations, which may include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, we may use and disclose your protected health information for purposes of improving clinical treatment and patient care. Individuals Involved In Your Care: We may from time to time disclose your protected health information to designated family, friends and others who are involved in your care or in payment of your care in order to facilitate that person's involvement in caring for you or paying for your care. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share limited protected health information with such individuals without your approval. We may also disclose limited protected health information to a public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other persons that may be involved in some aspect of caring for you. Business Associates: Certain aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, outcomes data collection, legal services, etc. At times it may be necessary for us to provide your protected health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, we require these associates to appropriately safeguard the privacy of your information. Appointments and Services: We may contact you to provide appointment updates or information about your treatment or other health-related benefits and services that may be of interest to you. You have the right to request and we will accommodate reasonable requests by you to receive communications regarding your protected health information from us by alternative means or at alternative locations. For instance, if you wish appointment reminders to not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. With such a request, you must provide an appropriate alternative address or method of contact. You also have the right to request that we not send you any future marketing materials and we will use our best efforts to honor such requests. You must make such requests in writing, including your name and address, and send such writing to the Privacy Officer at the address below. Research: In limited circumstances, we may use and disclose your protected health information for research purposes. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board which oversees the research or by representations of the researchers that limit their use and disclosure of your information. Fundraising: We may use your information to contact you for fundraising purposes. We may disclose this contact information to a related foundation so that the foundation may contact you for similar purposes. If you do not want us or the foundation to contact you for fundraising efforts, you must send such a request in writing to the Privacy Officer at the address below.Other Uses and Disclosures: We are permitted and/or required by law to make certain other uses and disclosures of your protected health information without your consent or authorization for the following: Any purpose required by law; Public health activities such as required reporting of immunizations, disease, injury, birth and death, or in connection with public health investigations; If we suspect child abuse or neglect; if we believe you to be a victim of abuse, neglect or domestic violence; To the Food and Drug Administration to report adverse events, product defects, or to participate in product recalls; To your employer when we have provided health care to you at the request of your employer; To a government oversight agency conducting audits, investigations, civil or criminal proceedings; Court or administrative ordered subpoena or discovery request; To law enforcement officials as required by law if we believe you have been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law; To coroners and/or funeral directors consistent with law; If necessary to arrange an organ or tissue donation from you or a transplant for you; If you are a member of the military, we may also release your protected health information for national security or intelligence activities; and To workers' compensation agencies for workers' compensation benefit determination.
DISCLOSURES REQUIRING AUTHORIZATION:Psychotherapy Notes: We must obtain your specific written authorization prior to disclosing any psychotherapy notes unless otherwise permitted by law. However, there are certain purposes for which we may disclose psychotherapy notes, without obtaining your written authorization, including the following: (1) to carry out certain treatment, payment or healthcare operations (e.g., use for the purposes of your treatment, for our own training, and to defend ourselves in a legal action or other proceeding brought by you), (2) to the Secretary of the Department of Health and Human Services to determine our compliance with the law, (3) as required by law, (4) for health oversight activities authorized by law, (5) to medical examiners or coroners as permitted by state law, or (6) for the purposes of preventing or lessening a serious or imminent threat to the health or safety of a person or the public.Genetic Information: We must obtain your specific written authorization prior to using or disclosing your genetic information for treatment, payment or health care operations purposes. We may use or disclose your genetic information, or the genetic information of your child, without your written authorization only where it would be permitted by law. Marketing: We must obtain your authorization for any use or disclosure of your protected health information for marketing, except if the communication is in the form of (1) a face-to-face communication with you, or (2) a promotional gift of nominal value. Sale of Protected Information: We must obtain your authorization prior to receiving direct or indirect remuneration in exchange for your health information; however, such authorization is not required where the purpose of the exchange is for: Public health activities; Research purposes, provided that we receive only a reasonable, cost-based fee to cover the cost to prepare and transmit the information for research purposes; Treatment and payment purposes; Health care operations involving the sale, transfer, merger or consolidation of all or part of our business and for related due diligence; Payment we provide to a business associate for activities involving the exchange of protected health information that the business associate undertakes on our behalf (or the subcontractor undertakes on behalf of a business associate) and the only remuneration provided is for the performance of such activities; 4 • Providing you with a copy of your health information or an accounting of disclosures; Disclosures required by law; Disclosures of your health information for any other purpose permitted by and in accordance with the Privacy Rule of HIPAA, as long as the only remuneration we receive is a reasonable, cost-based fee to cover the cost to prepare and transmit your health information for such purpose or is a fee otherwise expressly permitted by other law; or Any other exceptions allowed by the Department of Health and Human Services.
RIGHTS THAT YOU HAVE REGARDING YOUR PROTECTED HEALTH INFORMATION:Access to Your Protected Health Information: You have the right to copy and/or inspect much of the protected health information that we retain on your behalf. For protected health information that we maintain in any electronic designated record set, you may request a copy of such health information in a reasonable electronic format, if readily producible. Requests for access must be made in writing and signed by you or your legal representative. You may obtain a "Patient Access to Health Information Form" from the front office person. You will be charged a reasonable copying fee and actual postage and supply costs for your protected health information. If you request additional copies you will be charged a fee for copying and postage. Amendments to Your Protected Health Information: You have the right to request in writing that protected health information that we maintain about you be amended or corrected. We are not obligated to make requested amendments, but we will give each request careful consideration. All amendment requests, must be in writing, signed by you or legal representative, and must state the reasons for the amendment/correction request. If an amendment or correction request is made, we may notify others who work with us if we believe that such notification is necessary. You may obtain an "Amendment Request Form" from the front office person or individual responsible for medical records.Accounting for Disclosures of Your Protected Health Information: You have the right to receive an accounting of certain disclosures made by us of your protected health information after April 14, 2003. Requests must be made in writing and signed by you or your legal representative. "Accounting Request Forms" are available from the front office person or individual responsible for medical records. The first accounting in any 12-month period is free; you will be charged a fee for each subsequent accounting you request within the same 12-month period. You will be notified of the fee at the time of your request.Restrictions on Use and Disclosure of Your Protected Health Information: You have the right to request restrictions on uses and disclosures of your protected health information for treatment, payment, or health care operations. We are not required to agree to most restriction requests, but will attempt to accommodate reasonable requests when appropriate. You do, however, have the right to restrict disclosure of your protected health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the protected health information pertains solely to a health care item or service for which you, or someone other than the health plan on your behalf, has paid Orlando City Health and Wellness in full. If we agree to any discretionary restrictions, we reserve the right to remove such restrictions as we appropriate. We will notify you if we remove a restriction imposed in accordance with this paragraph. You also have the right to withdraw, in writing or orally, any restriction by communicating your desire to do so to the individual responsible for medical records.Right to Notice of Breach: We take very seriously the confidentiality of our patients’ information, and we are required by law to protect the privacy and security of your protected health information through appropriate safeguards. We will notify you in the event a breach occurs involving or potentially involving your unsecured health information and inform you of what steps you may need to take to protect yourself. Paper Copy of this Notice: You have a right, even if you have agreed to receive notices electronically, to obtain a paper copy of this Notice. To do so, please submit a request to the Privacy Officer at the address below.Complaints: If you believe your privacy rights have been violated, you can file a complaint in writing with the Privacy Officer. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services at the below address. There will be no retaliation for filing a complaint. Office for Civil Rights Department Federal Building26 Federal Plaza - Suite 3312 New York, NY 10278 Voice Phone (212) 264-3313; FAX (212) 264-3039; TDD (212) 264-2355
For Further Information: If you have questions, need further assistance regarding or would like to submit a request pursuant to this Notice, you may contact the [Orlando City Health and Wellness] Privacy Officer by phone at (407) 504-0117 or at the following address: 1320 S Orlando Ave Winter Park, FL. 32789.. This Notice of Privacy Practices is also available on our Orlando City Health and Wellness web page at www.orlandocityhealth.com
I have received a copy of the Notice of Privacy Practice from Orlando City Health and Wellness and have reviewed it carefully.

I hereby request and consent to the performance of chiropractic treatments (also known as chiropractic adjustments or chiropractic manipulative therapy), physical therapy (also known as PT) and massage therapy along with any other associated procedures including: physical examination, orthopedic testing, diagnostic x-rays, physiotherapy, physical medicine, physical therapy procedures, electrical stimulation, soft-tissue mobilization on me by the Doctor of Chiropractic, Doctor of Physical Therapy, Licensed Massage Therapist and/or medical assistants.
I understand, as with any health care procedures, that there are certain complications, which may arise during chiropractic treatments (chiropractic manipulative therapy). Those complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, Homers’ syndrome, diaphragmatic paralysis, cervical myelopathy, and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to arteries in the neck leading to or contributing to complications including stroke. I do not expect the doctor to be able to anticipate all risks and complications, and I wish to rely upon the doctor to exercise judgment during the procedure(s) which the doctor feels at the time, based upon the facts then known, that are in my best interest.
I have had an opportunity to discuss with the doctor(s) named above and/or with office personnel the nature, purpose and risks of chiropractic treatments and other recommended procedures. I have had my questions to my satisfaction. I also understand that specific results are not guaranteed.
I have read (or have read to me) the above explanation of the chiropractic treatments. By signing below, I state that I have been informed and weighed the risks involved in chiropractic treatments, physical therapy and/or massage therapy at this health care office. I have decided that it is in my best interest to receive chiropractic, physical therapy and/or massage treatment. I hereby give my consent to that treatment. I intend for this consent to cover the entire course of treatment for my present condition(s) and for any future condition(s) for which I seek treatment.

Thank you for choosing Orlando City Health and Wellness as your healthcare provider. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies. Patient Financial Responsibilities: The patient (or patient’s guardian, if minor) is ultimately responsible for the payment for treatment and care. Patients are responsible for payments of copays, coinsurance, deductibles and all other procedures or treatment not covered or approved by their insurance plan. Payments are due at the time of service. Non-covered items are due at the time of service or within 30 days of receiving a bill. If we do not receive payment within 60 days, your account will go into default and will be submitted to the IC Systems Collection Agency.
I understand by signing below I am responsible for all examinations performed in this office. I am declaring by signing below that I am responsible for any services not covered by the insurance company, including, but not limited to, co-pays, deductibles, co-insurance, etc. If Orlando City Health and Wellness is not in network with my insurance, I am willing to pay the self-pay rate for the initial examination, future examination, treatments and services rendered to me at Orlando City Health and Wellness. I fully authorize Orlando City Health and Wellness to bill me personally for all services rendered and that all money is due at the time of service unless I am on a membership at Orlando City Health and Wellness, whereas, services will be paid at the time of my monthly membership plan.
SAME DAY CANCELLATION, NO SHOW, NO CALL FEE:
By signing below, I understand that I am responsible for rescheduling or canceling my appointments no later than 24 hours prior to my appointment time. I understand that I must call to reschedule or cancel appointments within 24 hours of my scheduled appointment time to avoid a $40 no call/no show fee. By signing below I authorize Orlando City Health and Wellness to charge my card on file for the no call, no show fee or failure to reschedule or no show. The fee is listed below: No call/no show fee is $40

I certify to the best of my knowledge, the above information is complete and accurate. If I am not eligible to receive a health care benefit through this practitioner and location, I understand that I am liable for all charges for services rendered and I agree to notify the practitioner immediately whenever I have changes in my health condition. I understand that the medical professionals at Orlando City Health and Wellness may need to notify my physician if my condition needs to be co-managed. Therefore, I give authorization to the staff and medical team at Orlando City Health and Wellness to contact my physician, if necessary

WRITTEN DISCLOSURE FORM (F.S. 456.052)
Dr. Michael Gampolo has a financial interest in the following entities:

Orlando City Health and Wellness by Dr. Michael Gampolo
855 Outer Rd. Orlando, FL 32814
1320 S Orlando Ave. Winter Park, FL 32789

Walk-In Wellness
1046 Montgomery Rd. Altamonte Springs, FL 32714

As the patient you have a right to obtain the same items/services at one of the listed locations or at a different location of your choice. You may obtain these same items/services at the following locations where I do not have a financial interest:

UDI
111 N Lakemont Ave, Winter Park, FL 32792

Integrity Medical Group
1801 Lee Rd #304, Winter Park, FL 32789

Financial Responsibility have requested professional services from Orlando City Health and Wellness (“Provider”) on behalf of myself and/or my dependents, and understand that by making this request, I am responsible for all charges incurred during the course of said services. I understand that all fees for said services are due and payable on the date services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement unless other arrangements have been made in advance.
Assignment of Insurance Benefits hereby assign all applicable health insurance benefits to which I and/or my dependents are entitled to Provider. I certify that the health insurance information that I provided to Provider is accurate as of the date set forth below and that I am responsible for keeping it updated. I hereby authorize Provider to submit claims, on my and/or my dependent’s behalf, to the benefit plan (or its administrator) listed on the current insurance card I provided to Provider, in good faith. I also hereby instruct my benefit plan (or its administrator) to pay Provider directly for services rendered to me or my dependents. To the extent that my current policy prohibits direct payment to Provider, I hereby instruct and direct my benefit plan (or its administrator) to provide documentation stating such non-assignment to myself and Provider upon request. Upon proof of such non-assignment, I instruct my benefit plan (or its administrator) to make out the check to me and mail it directly to Provider. I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from Provider are paid in full. I also understand that I am responsible for all amounts not covered by my health insurance, including co-payments, co-insurance, and deductibles.
Authorization to Release Informational hereby authorize Provider to: (1) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing.
ERISA Authorization hereby designate, authorize, and convey to Provider to the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plan, as my Authorized Representative: (1) the right and ability to act on my behalf in connection with any claim, right, or cause inaction that I may have under such insurance policy and/or benefit plan; and (2) the right and ability to act on my behalf to pursue such claim, right, or cause of action in connection with said insurance policy and/or benefit plan (including but not limited to, the right to act on my behalf in respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R. §2560.5031(b)(4)) with respect to any healthcare expense incurred as a result of the services I received from Provider and, to the extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines. A photocopy of this Assignment/Authorization shall be as effective and valid as the original.

I agree to the terms & conditions https://www.orlandocityhealth.com/terms please see our privacy policy at https://www.orlandocityhealth.com/privacy-policy. I consent to receive these messages. Message frequency may vary, and message and data rates may apply. You can opt out at any time by replying "STOP." Your information will not be shared with third parties. By providing your phone number & email. I agree to receive text messages & email reminders from the OC. I understand the "No call no show fee."