412 West 42nd Street Kearney, NE 68845 Ph - Heartland Hematology And .
Heartland Hematology & Oncology, P.C.412 West 42nd Street Kearney, NE 68845ph - 308-865-2303 fax – 308-865-2304Patient:Appointment Date and Time:Please arrive 15 minutes early.The physicians and staff of Heartland Hematology & Oncology, P.C. welcome you to our clinic. Your health andwell-being are our primary concern. We hope the information provided here answers your questions about ourservices, policies, and procedures.PhysiciansDr. Cynthia M. Lewis, MD, is a Board Certified Hematologist/Oncologist. She received her undergraduate degreefrom the University of Nebraska, Lincoln, and received her medical degree from the University of Nebraska MedicalCenter, Omaha. She completed her Hematology/Oncology Fellowship at the University of Nebraska Medical Center,Omaha.Dr. Nick J. Hartl, MD, is a Board Certified Hematologist/Oncologist. He received his undergraduate degree fromthe University of Nebraska, Kearney, and received his medical degree from the University of Nebraska Medical Center,Omaha. He completed his Hematology/Oncology Fellowship at the University of Iowa Hospitals and Clinics, IowaCity, Iowa.General InformationThe clinic is open to serve you, answer your questions, or schedule an appointment Monday through Friday from8:00 am until 5:00 pm. After hours, an on-call staff member is always available should you need care when the clinic isclosed. By calling the main number, you will be given information regarding on-call staff.AppointmentsWe will do our best to keep our appointment schedule. However, please understand that not all patients require thesame amount of time with the doctor and that emergencies do occur, so some delays are unavoidable. We will do ourbest to keep you informed of delays. Your patience in these situations will be greatly appreciated.History InformationEnclosed you will find forms that we ask you to complete. Please return before/bring to your appointment. If you areto return the forms, we have enclosed a return envelope for your convenience. This will enable our clinic to establishyour file and gather necessary information to facilitate the appointment. Please fill out each form as completely aspossible. Some forms do have questions on both the front and the back of the page.RegistrationOn your first visit to Heartland Hematology & Oncology, P.C., you will be asked for verification of basicinformation to complete your medical record and business account. Please bring your current insurance cards anda photo ID at that time. We also ask that you notify our office of any changes in name, address, phone number, orinsurance coverage as soon as any change occurs.FeesOur charges for services are based on the severity and complexity of your illness or service need as required underfederal guidelines. After discussion with you and a complete review of your medical records, a plan of care will bedetermined to best treat your individual needs. A financial representative will be pleased to discuss our fees with you.Please do not hesitate to inquire about the charges for our services.
InsuranceOur financial representative will submit primary and secondary insurance claims for you--subject to your having givenus current insurance information prior to the service being provided. Policy coverage varies from one insurance plan toanother, as do the “usual, customary and reasonable” fees that various insurance plans have established. Our fees areaccepted by most plans, but occasionally one of our patients is notified that the amount for our service exceeds “UCRFEES”. To avoid disappointment, we strongly suggest that patients contact their insurance company to make certaintheir medical insurance assumptions are correct. Pre-certification of any services, if required by the insurance company,is the responsibility of the patient. Contact our financial representative if you have any questions regarding precertification. Some patients have cancer insurance policies that will help to cover services provided. Please notify uswith information regarding any cancer policy you may have so we can help facilitate these amounts toward payment ofyour bill. If at any time you are in need of a billing statement to send to a cancer insurance plan, please contact ourfinancial representative.Our contractual arrangement for payment of all services is with you, our patient, not your insurance company. Shouldthere be a dispute related to the service provided or the charge for that service, the settlement of that dispute is betweenyou and your insurance carrier. Our office is not involved in the settlement of such disputes. The final responsibilityfor payment of the services provided to you is yours.Financial ArrangementsCharges are payable at the time of treatment or when service is provided. Regardless of your medical insurancecoverage, our office relies on you to settle your account. In order that we may have a definite understanding regardingthe payment of fees, please review the following:A.Cash Payment Plan. Payment of the portion of the medical services your insurance will not cover (copayment or deductible) is due and payable on the day the service is provided. Payment for these services maybe paid by cash, personal check, debit or credit card (VISA or MasterCard).B.Statement Plan. Payment of the balance in full upon receipt of your statement. Payment may be paid bycash, personal check, debit or credit card (VISA or MasterCard). Please contact a financial representative ifyou would like to authorize that monthly balances be charged to your credit card.C.Personal Loan. For balance amounts you are unable to pay in full upon receipt of your statement, we askthat you make arrangements with a lending institution for a payment plan. After credit is approved, thelending institution will pay the balance due, and you may repay their loan over a period of months atprevailing bank rates.D.Monthly Payment Plan. Arrangements can be made to have an automatic payment withdrawn from yourchecking account on the 28th of each month and sent directly to Heartland Hematology & Oncology, P.C.Please contact our financial representative to complete the paperwork.If other arrangements are needed please talk to a financial representative PRIOR TO receiving service.Patient AssistanceSeveral Foundations and drug companies are available to provide help to patients that qualify for assistance. This caninclude assistance with medications and insurance copays. Before treatment, our staff will check if you qualify forassistance and we help our patients through the process. If you have questions, please talk to our staff.Workers CompensationAs a courtesy to our patients, our financial representative will file workers compensation claims. However, if the claimis denied, unsettled, or is not paid within 60 days from date of service, we request that you file a personal healthinsurance claim or pay the charges in full. You should always notify your company if there is any delay or problem inresolving your workers compensation claim. Unreasonable delays or the use of delaying tactics should be reported tothe office of the Insurance Commissioner of Nebraska.Thank YouWe appreciate your selection of Heartland Hematology & Oncology, P.C. to meet your health care needs. We arecommitted to you to do the very best we can to provide you with the very best of care. Our staff—practitioners,nurses, technicians, clerical, and administrative—work as a team. We take great pride in our training, abilities, anddedication and hope you will soon share in our confidence. Your suggestions and comments are always welcome, andshould you have any concerns, PLEASE give us a chance to discuss them with you.
I{eartland Flematology & Oncology\ cst 42"'r Strcet Kearney, NE 68845I'hone: (308) 865-2303 Fax: (308) 865-2304412Patient's Narne(firut)(nriddlePlirnaly Cale Physician:initial)(last)Patient AddlessReferriug Physician:(st/ú/l/box#)(city)(EMAII- ADDIìI]SS)(zip)(state)Patie¡rt Horne PhonePatient Cell Phone:Sex: MaleDate of Birth:rraleSM WDMâr'ital Status:Social Seculity Nr.rrnber':PleÎe¡r'ed LangLrage:lreEnglish SpanishOther'Ethnicity:IìaoeErnployment Status: lìulll-imePaltOtherll ispan iclLatino Not llisparricTime RetiledLatino Rulise to lupor1Disabled HomenlakerStr¡dentJob'litleEnrployer:Errployer PhoncEurployel Addless(city)(st/r1#/box#)Spouse Namc:Spouse JobEmployel Address:Title:(city)(st/rt#/box#)Ernployel Phone(sta1c)l)alent GualdianPower ofI{esponsible Party Addless:I-lonre PhoneAftorneyOfhe¡'(city)(st/r(#/box#)(stale)Cell Phone:Insurance IrrformationNunlber':Medicaid NurnberPrimary Insulance Company Name:Policy #:(zip)(if Minor ol Othel Iìeason):Relationship (circle one)Medicale(zip)Spouse Cell Phone:Spouse Employer':Responsible Pady(stâte)-, -St¡bsclilrel Name (pelson rr4ro call ies the insurance)Subscliber's date ol' birth:Pleasc complete information on revcrse sidc.Gloup ID #ssN(zip)
Heartland Hematology & OncologyNameSecondary Insurance Company NamePolicy #Group ID #Subscriber Name (person who carries the insurance)Do you have a cancer policy? YesNoIf yes, ask about help to get the claim processing information.If you do not have insurance, how to you intend to pay for your services?CashCheckCredit CardAdvance DirectiveDo you have a Living Will? YesNoPower of Attorney for Health Care? YesIf you do, please bring to the clinic to be scanned and kept on your chart.NoDNRYesNoPharmacy InformationPreferred Local Pharmacy:Location:(city)(state)(zip)Mail Order/Specialty/Medicare Part D Pharmacy:(If Medicare Part D, will need to scan card)Nearest Friend or Relative Not Living with You (Emergency Contact)Name:Home Phone Number:Relationship to Patient: Cell Phone Number:Address:(st/rt#/box#)(city)(state)(zip)Do you have a Federal Black Lung Card?Are you a Veteran?Yes No Yes No Did the VA refer you here for treatment?Are you covered by an employer’s health insuranceYes No plan through your employment or that of a familyDo you have a VA “Fee Basis ID Card”?member? (Not Retiree Coverage)Yes No Yes No Is this medical Condition due to an accident of any kind?Yes No (If you answer yes please complete the following) Work Related Injured in your home Auto Other Your physician may request your permission for a healthcare provider not associated with the practice, (i.e. a physicianresident in training) to accompany them during the office visit. If you deny the request, your physician will comply withthe denial.I authorize the release of my medical records from this office, as well as records obtained from other facilities pertinent tomy treatment plan, to other medical facilities as necessary for continued care. I authorize Heartland Hematology &Oncology to take a photograph of me and keep this photograph in my file for identification purposes.I authorize disclosure of portions of my medical record to my insurance provider to determine liability and to obtainreimbursement. I assign all medical/surgical benefits for which I am entitled to Heartland Hematology and Oncology, PC.I understand that CHARGES ARE PAYABLE AT THE TIME OF TREATMENT. I further understand that I amfinancially responsible for all charges whether or not paid by said insurance.I hereby authorize Heartland Hematology and Oncology, P.C. to render medical services to me.DATE SIGNATURE
Heartland Hernatology/Oncology412 West 42nd StreetKe amey, NE 68845Patient Name(-uclcxYorNofn/îREVIEW OF SYSTEMSGENERAT\X/eight Cìain.llcvctChillslìatigu cI lot. lìlasìrcsNìght Sl,catsParYNrYNnfltY N\a NYNn/ J9t91 tl4n¡/ Y N n/a,YNnfal,ocalionSKINlìr:LrisingNcrv LesrolsI)ryncs"lì.ashY NYNnfzYN\/ YNnfa)oint StiffnessMusclc PainN,Iusclc tù7eal ncssIFleadacheVisual l)isturbancesI learing l,ossNasaì CongestionSeasonal ,{llciqicsMouth Sr resSore'Ì'hroatI))ccding GumsDouble \/isionDty ily".Nosc lllcedsY NYNn/aY NYNnfaMood SwingsÂ1.¡xieqlUnable to Conccntrate!1/ar i/.aYNnf¿'Y N nf ttYNnfa.Y- N n/aYNn/aYNnfz.YNnfaRESI'IRAIORYShc¡ltncss of IJreatl.rYCoughSpututn P.toductior.rCoughing u¡r lllood\aCARDIOVA.SCULARlrrcgular Heart lìhythmChcst ì)ainLiclemalìlcvatccl minal PainlJloocl in SroolsConsfi¡rationl)ralhcaDifhculry SrvallorvingNauscaVor.nitilgYYNNNNn/tn/ n/ar/ n/ nft:]fa1\YN\/rYNnfa\YYYNNnfYYYYN rfaN nf¡N nfaN rfaN n/ HEMATOLOGYÁúnol.,rol lìlecctingFlistory of llloocl ClotsLirlargecì ì.,yr.r.rph NodesIÌasy JltuisingNNa.nfanfa¡faYNlr'faY N rf ttYN:nfl¿YNnfaIMMUNOLOGYHistory lrdrlclYYYNi/ NNNnfan/anfaN n/ N nfaN nftGENITOURINARYAllinC.,¡rtine¡iccUrincVoid l'lrcgucntlyYY)a'I'irncs Voidìngrr NighrWorne nAgc of 1 st ì)eriocì:-i\gc of 1st l.,ivc lltth:\ßc oI Mcrr,rPausc:l\lc¡rstlurIjun # ,rf I )rys;J -cn*rìr c,f (.t clc:YNnfaYNlnfaYN\/aìnf.n/anfanfanfan/aD/ Y NYNnfaNYl)tittculq, Slec¡rrnglJloocl lnYNYNYNYN\.NYvPSYCHIATRIC1)cprcssionHEENTr/ t/ vNNNNNNYYYIlacl PainIion" PaìnYNr'/ r\ppctjtc h li:rc.n/itnfr.Menl'lcsitancy'fi:oublc StartilrgStream\a NYL1f N t/a
[Icartland I{crnatology & Oncology412 West 42r'd Strcct Kcarncy, NE 68845Phone: (308) 865-2303 Fax: (308) 865-2304Patient Historv FormName:Reason for Visit:DatePast Medical History (all health diaenosis& pertinentPneumonia Vaccine: YÀl Date:Colonoscopy: Y/N Date:Facility location:illnesses):Influenza Vaccine: Y/N Date:Recent Fall(s): YÀtr Date:Past Surgical History (with approx. dates):Familv Medical l{istory:Familv Member:SocialDia gnosis:Living or Deceased:llistorv:Smoke or Tobacco Use: Y/N # of years? PacVs per day: When did you quit?Alcohol Use: Y/N # of'drinks per': I)ay:- 'Week;' - , '-*,Month:.-,. , Year:Married / Single / Widowed / Divorced Number of ChildlenOccupation:
llcartland Hcmatology & Oncology412 Wcst 42"d Stleet Kcarncy, NE 68845Phone: (308) 865-2303 Fax: (308) 865-2304Patient Medication ListMedications ( Including over the counter and herbals):DlugDosageTinres ¡rel dayDrugDosage'l'imes pel dayDlugDosage'l'iures pcr dayDr ugDosagelimes per dayDrugDosage'l'imes pel dayDrugDosageTimes per dayDrugDosageTimes per dayDrugDosage'limes per dayDrugDosageTirnes per dayDrugDosageTimes per dayDrugDosagcTimes pel dayDrugDosageTirnes pel dayDlugDosagc'Ì'incs pel dayAllersies:Ì)it;ñt-Drug oÌ I yDcDmg ol Typel)r-ug or- 'ly¡rcDrug or 'ly¡reDrug ol Typer À;irtp;Drug or'l\pe
IìEQUEST FOR RELEASE OF MBDICAL RECORDSFrom:ADDRESS:CITY:STATE:ZIP:PLEASI] INCI,tJDI]'f[{E FOLLOWING:IIISTORY AND PHYSICALDISCIIARGE SUMMARYLABD(-RAY REPORTSOTIJER:ALL MEDICAL RECORDSI HEREBY REQUEST THAT MY MEDICAL RECORDS BE R.ELEASED TO:Heartland Hematology & Oncology, PC412 West 42nd StreetKearney, NE 68845PI-IONE: (308) 865-2303(308) 86s-2304FAX:PATIENT PRINTED NAMEDATE OF BIRTHADDRESS:CITY:STATE:ZIP:PATIENT SIGNATTIREor AIITI{ORIZED REPRIISEN'I-ATIVE SIGNATUREDATEReason
Healtland llematology & Oncology P. C.Street l(eârney, NE 68845Phone: (308) 865-2303Fax: (308J 865-230441,2 W est 42",tReceipt of Notice ofPrivacy Practices (HIPAAJWritten Acknowledgement Formhave ¡eceived â copy of Heartland Hemâtology & Oncology P,C.'sNotice of Privacy PracticesSigÌrature of Pâtient or PclsonaÌ Represent¿rtiveRecipient, Hea tland He¡natology& 0ncology, P,C., tal(es patient privacy seriously. HHO pet'sotinel useanddisclose patient health infonnation only as pennitted by HHO policies and applicable law. Such poÌices and lawpelmit HLl0 personnel to djsclose a patielìt's health information to friends and family nrembers designated by thepatient. This voluntary form alìows you to desiglìate the friends and family members to who HHO personnel maydisclose infolnration about youl health care, as welì as the information that may be disclosed. The folìowingpersons or orgânizâtion are to receive the personaÌ health information:RelationshiNanìePhone Number'Explanation of Rights, I understand thât:. I can revol e this authorization at any time by giving my written revocation to tlìe Disclosing Provider'. Myrevocation is not effectìve as to disclosure already made and actions already tal en in reljance upotr thisAuthorization.o The disclosing provider may NOT condition treatment, enrollment irì the heaìth pìan or eligibility l'orbenefits on wliethei'I sign tÌìis Auth0ì'izatìon. I am authorizing clisclosr:r'e ol'inlol'mation protected under federal law, l'his information, ônce clisclosed,nlay be subject to re-disclosure by the recipient and no longer be protected by stâte or federal law.Signature of Patient or Personal RepresentativeRepÌesentative's Relationship to Patient [if applicable)DateRenewal of Privacy Practice Policy. I have read and uuderstand the above inforrnation and I reauthorize the above people to receive te/lnitialsDate/lnitiâls
ft'#eartlandy&Oncology412W.Kearney,Phone 3OB-865-2505Fax 5OB-865-2õO4Cynthia M. l-ewis, MDNicholas J. Ilarll, MDCeorge K. Bascotn, MDNurse Navigator ProgramHeartland Hematology & oncology has started a nurse navigator program for our patients d¡agnosedwith cancer and blood disorders. This nâvigator service is to help you and your loved ones as you 8othrough th¡s journey by offering support and informðtion. The goal of navigat¡on serv¡ces ìs to prov¡deassistance to assure you rece¡ve timely, quality treatment for your disease. The nav¡gator works w¡th allhealth care professionals to remove barr¡ers that stand in the way of effective, comprehensive cancerand hematology care. Our nurse nâv¡gators are experienced oncology nurses who are there to help youunderstand and adhere to your treatment plan and changes in your l¡fe it may requ¡re. These serv¡cesare available to you from the t¡me of diagnosis through treatment and into survivorsh¡p.The nurse nav¡gator can help you accomplish any of the follow¡n8:1) Provide ¡nformation needed to make decisions.2) Give information on what to expect during appointments and treatments.3) Help arrange appo¡ntments with other phys¡cians and support services such as physical therapy,transportation serv¡ces4) Assist w¡th translat¡on/¡nterpreter serv¡ces.5) ldentify sources of financial support and ¡nsurance ¡ssues.6) Share information about cl¡nical research trials available.7) Provide support and understanding through treatment.Heartland Hematology & Oncology's Nurse Nav¡gators42nd St.E 68845
HEAIìTLAND HEMATOLOGY & ONCOLOGY, P.C,NOTICE OF PRIVACY PRACTICESAs Requìr'ed by the Plivacy Iìegulations Created as a Result ofthe l-ìealth lnsulance Portability andAccountability Act of I 996 (lllPAA)THIS NOTICE DIISCRIIìES HOW HEALTH INFOIì.MATION AIIOUTYOU (AS A PATTENT OF]'HIS PIìACTICII) MAY I}E USED ÄND DISCLOSED, AND HOW YOU CAN GIIT'ACCIISS TOYOUII INDIVIDUALLY IDENTIFIA.BLE HEALTII INFORMATION.PLIIASE IIEVIIìW THIS NOTICE CAREFI]LLY.A. OUIì COMMITMENT TO YOUR PII.IVACYOnl practice is dedicaled 1o mainlaining the privacy ol'youl individually identilìable health information (ìllìl),hl conducting oul business, we will cleate lecords legarding you ancl the treatn'ìent alid selvioes we plovide toyou. We are required by law to rnaintain the confidentiality of health infolmation that identiiìes you. We alsoare required by law 1o provide you with this notice ofoul legal duties and the privacy plactices tlrat we maintainin our praotice conceining youl lll{1. By fedelal and state law, we must follow the terms ofthe notice ofplivacy practices that we have in effèct at this time.We realize that these laws are oomplioated, Lrut we must plovide you wiÙr the f'ollowing impo tant infbrrnation:.oHow we may use and disclose youl IIHIYour plivacy lights in youl IIIIIOul obligations concerning the use and disclosule ofyoulIIIII'fhe terms of this notice apply to all records containing your IIIII that are creatcd or rctained by ourpractice. We reserve the right to rcvise or amend this Notice ofPrivacy Practiccs. Any revision oramendnrent to this nofice will bc effcctivc for all ofyoul'records that our practicc has created ornaintained in the past, and for any of your rccords that we may create or maintain in thc futurc. Ourpr:tcticc will post a co¡ry of our current Notice in our offices in a visiblc locafion af all tinles, and vou mayrcqucst â co¡ry of our rnosf currcrrt Noficc at any tirno.B. I¡- YOU HAVE ANYQUDS'TIONS AI}OUT'IHIS NOTICE, PLì'ASD CONTACT:Ileartland l-Iernatology & Oncology, P.C.412 West 42"d StlcetKcarne¡,, NE 68t145308-86s-2303
USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTIIINFORMATION OIHI) IN THE FOLLOWING WAYSC, WE MAY'l'he following categolies describe the diffelent ways in which we may use and disclose your IIIJLl.to treat you. For exarnple, we rnay ask you to havelabolatoly lesfs (such as blood or urine tesls), and we may use the lesults to help us reach a diagnosis.We rright use your IIIrll in older to wrilc a prescliption for you, ol we might disclose youl IIHI to apl.ralrlacy when we older a presc;r'iption for you. Many of 1he pco¡rle who wolk lil ou: placticeincluding. buL not limiled to, oul doclols and nulses - rìray use ol disclosr: youl IIIII in oldel to treat youor to assist othels in your tleatrnent. Additionally, we may disclose your llHl to othets wlro rnay assistir.r youl care, suclr as youl spouse, children ol'pal'euts. Finally, we may also clisclose your lllll to other'liealth cale ploviders lbl pu:'poses lelaled 1o your trcaturent.2.Payrnent, Oul plaotice nìây use and disclose youl IIHI in oldel to bill and collect payment fol theselvices ¿rncl itenrs you may leceive fiour us, Iìor exam¡rle, we uìay oolìtacl yorn hcallh insulel to certil)that you ate eligible for benefits (and for what range ofbenelìts), and we r.nay plovide youl insurer witl.rclefails regalding your tleatrent to detelmine if your insuret will cover', or pay for', youl'trealment. Wealso may use and disclose youl IlHl 10 oblain paymenl frorn thild parties that may be responsible for'such costs, such as family members. Also, we may use your IIHI to bill you direclly for services anditelns. We rnay disclose your IIFII to other health oare providers and entilles to assist in tlieir billing andcollection efl''olts.3.youl III{I to opelate oul business. Asexamples of tho ways in which we may use and clisclose your information for our opelations, our'practice rnay use your IIHI 1o evaluale the quality ofcale you leceived from us, or to conduct costÍnanagement and business planning activities f'ol our praclice. We rnay disclose your IlHl to otherÌrealth care providers and entilies 10 assisl in thei¡'health care operations.4,Appointment lìcmindcrs. Our plaotice lnay use and disclose your IIHI to contact youof'an appointnent.5.Treatment Options. Oul plactice ÍìrayTreatment. Oul plactice mayuse yourlllllllealth Carc Operations. Oul praclice Ínayì-ìseuse and discloseand disclose youlIllllancllemind yonto inlàr'm you of polentiâl treatmentoptions or alternatives.6.Health-Iìelated Bcncfits and Scrvices. Our praclice may use and disclose yourhealth-relaled beneljts ol services thal may be of inleresl to you.7.Rclcasc of information to Family/Fricnds. Oul plactioe nray lelease your lllll 1 l a fiiend or lànrilyrnember lhat is involved in youl cale, ol who assists in taking cale of you. Fol example, a parent or'guardian rnay ask that a babysitter take theil child to the pediatlician's office fol tlealrnent ofa cold. Inthis example, the babysitter may have accoss to this child's neclical infornation.8.Disclosures lìcquired By Law. Oul plactice will use and clisclose yourdo so by fedelal, state or local law.IIIìIllHlto inlbrrn youofwhen we are lequired to
D, USIì AND DISCLOSUIIE OF YOUR IIHI IN CEIITAIN SPECIAL CIIICUMSTANCESThe following catcgolies describe unique scenalios in which wc nlay use or disclose your identifìable healthinfolmation:l.Public Health Rishs. Oul practicc rnay disclose youl III{I to public health authorities that areauthorized by law to colleot information lòr' the purpose o1':c¡o.oo¡o.r.nainlaining vilal recolds, such as births and cleathsr'epollir]g cliild abuse or negleoLpreventing or contlolling disease, injuly ol disabilitynolilying a persolì r'egarding potential exposule to a col¡municable diseasenotifying a person regarding a poter.rtial risk for spreading ol colÌtracting a disease ol'conditionrepot'ting reaclions to drugs or problelns with products or devicesnotifying individuals ifa ploduct ol device they may be using has bccn reoallednotifying applopriate governrnent agency(ies) and autholity(ies) r'egaldir-rg the potential al¡use orneglect of an aclult patienl (including donrestic violence); however, we will only disclose thisinforlnatior.r if the patient agrees or we are required or autholized by law to disclose thisinlon¡ationnotifying your employer under lirrited circumstances related primarily to wotkplace injuly orillness or medical surveillance.2.Health Ovcrsight Activities. Oul plactice may disclose your III-ll to a health oversight agency folactivities authorized by law. Ovelsight aclivities can include, for example, investigalions, inspections.audits, surueys, licensule ancl disciplinary actions; civil, administlative, and criminal plooedures or'actions; or olhel activities necessaly fol the governmcnt to rnonitor government pl'ograms, compliancewith civil lighls laws and the heahh oare systenl in general3.Lawsuits and Similar Proccedings. Our practioe may use and disclose youl ilHl in response to a cor¡rtor adrninistlative order, if you are involvecl ir.r a lawsuit o1'similal ploceedirrg. We also may discloseyoul lILll in response to a discovely lequest, subpoena, or other lawlil process by another paltyinvolved in the clispule, bul only if we have r.nade an efïòrt to inl'olrn yon ofthe lequcst or to obtain anordcr protecting the infbluration the pal ty has requested.4. l,¡w Enforccment.o.oWe may releaseIIIII if asked to do so by a law eulòrcelnent ofíìcial:llegarding a orinre victirn in celtain siluations, i1'we ale ur.rable to obtain the pelsor.r's agreenlenlConcerning a deatl.r we believe has resulted fì'orrr crinrinal conductRegalding orirlinal conducl at on¡'oflìcesIn lesponse to a warrant sumn'ìons, ooult older', subpoena or siurilat legal plocess'Io identify/locate a suspect, material witness, fugitìve ol missing pclsonIn au eÍnergcrlqy, to r:eport a crirne (including the location or victim(s) ofthe crinre, or thcdescliptior.r, identity ol locatior.r of the perpetlator')
5.Deccased Paticnts. Oul plactice rnay release lllIl to a medical examiner or corolìel to identify adeceased individual ot to identily the cause of death. If necessaly, we also rnay release information inorder for l'unelal ditectols to pelfolm theil jobs.6.Organ and Tissue Donation. Our practice rnay release youl llFll to olganizations thal har.rdle organ,eye or tissue procul'ement o[ t ansplantation, including organ donation banks, as r'ìecess¿uy to facilitateorgan ol tissue donation and tlansplantation ifyou are an organ donor.7,Rcsearch. Oul plaolioe rllay usc al'ìd clisclosc your lllll f'ol research purposes in certain limitedoircumsta:rccs. We will obtain youi: written autholizatiorì 10 use youl Jllll fol lescalch purposes exccptwhen hrternal or Review Board ol Privacy Iloard has determined that the waiver of yor"rr authorizationsatisfies tlìc lòllowing: (i) the use or disclosul'c iuvolves no lr.ìore than a nrinimal risk to youl plivacybasecl on lhe following: (A) ari adeqLrate plân to protect the identifìers lì'om implopet usc and clisclosule;(B) an adequate plan to deslroy the ideritifìels at the earliest opporturiily consistent with the research(unless thele is a health or lesearch justification for letaining the identifiels or such lelention isothelwise recluilecl by law); and (C) adequate written assuLarìoes that the PIII (Plolcctecf FlealthInfomration) will not be re-used or disclosed to any other person or entity (except as lequired by law) forauthol izecl oversight of the research stucly, or fol other research fol which the use or disclosure wouldotherwise be permitted; (ii) the resealch could not placticably bc cor.rd¡,rcted without the waiver; and (iii)the lesealch coulcl not practicably be conducted without access to and use of the PHl.8.Serious Threats to Hcalth or Safety. Oul practice may use and disclose youl IIHI when necessary toreduce or prevent a serious threat to your health arid safety or the health and safety ofanothel indiviclualol the public. Undel these cilcurnstances, we will only make disclosures 10 a person ol organizationable to hclp plevent the threat.9. Milifary.Our practice may disclose your III-ll if you are a membet of U.S. or foreign rnilitary forces(including veterans) and if'required by the appropliate autholities.Security. Onr practice nray disclose your lllìl 1o f'ederal o1.1ìcials lbr intelligence and nationalseculity aclivities autbolizecl by law. We also may disclose youl IILII fo federal olTìcials in ordel toprotect the President, othel officials or foleign heads of state, or to conduct investigations.10. National11,12.Inmatcs. Oul praotice rnay disclose your llHl to cotrectional inslitutions or law r:nforcernent officialsyou ale aÌl ilu.nate ol undel thc custody o1'a law culbroement olïìcial. Disclosure f'ol thcsc pulposeswould be necess¿ìry: (a) for the insLitulion to provide health cale selvices to you, (b) lbl tlie salèty andsecurity ofthe instilution, and/ot (c) to protect yonr health and salè1y or the health and salèty ofotherindividuals.Workers' Compensation. Our plactice may release yourproglallls.lllllfol wor'l ers' cornpensation and sirnilarif
E. YOUR RIGHTS REGARDING YOUR IIHIYou have the following righls regalding rhe IIHI lhat we maintain aboul you:l.Confidential Communications. You have the right to request that our practice conlr¡unicate with youaboui your health and relatecl issues in a paltioular marlue
Heartland Hematology & Oncology, P.C. 412 West 42nd Street Kearney, NE 68845 ph - 308-865-2303 fax - 308-865-2304 . Please bring your current insurance cards and a photo ID at that time. We also ask that you notify our office of any changes in name, address, phone number, or . NE 68845 I'hone: (308) 865-2303 Fax: (308) 865-2304 Plirnaly .
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N. Suttle 2010. Mineral Nutrition of Livestock, 4th Edition (N. Suttle) 1 1 The Requirement for Minerals Early Discoveries All animal and plant tissues contain widely vary-ing amounts and proportions of mineral ele-ments, which largely remain as oxides, carbonates, phosphates and sulfates in the ash after ignition of organic matter. In the .
