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Welcome to the ACMG Health Enroll page ! You have just entered a private secure work area that utilizes a technology called SSL Encryption in order to protect any private information that your employer's insurance carriers need to administer your family's benefits. Your employer recognizes your need for privacy and has agreed to adhere to restrictions that prevent them from viewing any health information of any employee in any individually identifiable way.

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Instructions: Enter Your Legal Last Name and First Name (Do Not Include Spaces or Apostrophes) Do Not Include Any Middle Name or Initial Do Not Include Prefix (for example- Dr., Mr., Mrs., etc.) Do Not Include Any Suffix (for example- Sr., Jr. II, III, etc.)
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About SSL security: SSL is an acronym for Secure Sockets Layer. SSL provides a secure connection, allowing you to transmit private data online. Sites secured with SSL display a padlock in the browsers URL along with HTTPS address. When a user connects to a website via HTTPS, the website encrypts the session with a digital certificate. A user can tell if they are connected to a secure website if the website URL begins with https:// instead of http://. All web browsers have the ability to interact with SSL secured sites so long as the sites SSL is from a recognized Certificate Authority, such as Comodo.

We care about the privacy of your Protected Health Information (PHI). We are required by law to maintain the privacy of that information and to provide you with this Notice of our legal duties and our Privacy Practices. This document will also serve as your authorization for Secure Enroll Inc., and Certified Health Enrollment Services to use your PHI for the purposes detailed below.

Health Plan Enrollments and Modifications We will release PHI as required by your health, dental and other insurance carriers in order to enroll you on your insurance policy(ies). In this role we are acting as intermediaries in communicating your information entered on our website to your insurance carriers.

Treatment We may disclose medical information about you to your personal doctor or to other health care providers who take care of you. For example, we may notify your personal doctor about treatment you receive in an emergency room. We might also use health information about you to help you manage your health care by suggesting ways to improve your health.

Payment We may use and disclose medical information about you so that the medical services you receive can be properly billed and paid for. For example, we may ask a hospital emergency department for details about your treatment before we pay the bill for your care.

Health Care Operations We may use and disclose medical information about you for our operations. For example, we may use medical information about you to review the quality of services you receive or to seek accreditation.

Copies of this Notice You have the right to receive an additional copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.

Changes to this Notice We reserve the right to revise this Notice. A revised Notice will be effective for medical information we already have about you as well as any information we may receive in the future. We are required by law to comply with whatever Privacy Notice is currently in effect. Changes to the privacy policy will communicated in a timely manner to all currently active members of our website.

Your Right to Inspect and Copy Upon written request, you have the right to inspect the health information we maintain about you and to have copies of that information.

Your Right to Amend If you feel that the medical information about you which we have is incorrect or incomplete, you can make a written request to us to amend that information. We can deny your request for certain limited reasons, but we must give you a written basis for our denial.

Your Right to a List of Disclosures Upon written request, you have the right to receive a list of our disclosures of your medical information, except when you have authorized those disclosures or if the disclosures are made for treatment, payment or health care operations. We are not required to give you a list of disclosures made before April 14, 2003.

Your Right to Request Restrictions on Our Use or Disclosure of Information If you do so in writing, you have the right to request restrictions on the medical information we may use or disclose about you. We are not required to agree to such requests.

Your Right to Request Confidential Communications You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Your request must be in writing. For example, you can ask that we only contact you only at work or only at a certain address or only by mail.

How to Use Your Rights Under This Notice If you want to use your rights under this Notice, you may call us or write to us. If your request to us must be in writing, we will help you prepare your written request, if you wish.

Complaints to the Federal Government If you believe your Privacy rights have been violated, you have the right to file a complaint with the federal government. You may write to: Office of the Secretary, Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201. You will not be penalized for filing a complaint with the federal government.

Complaints and Communications With Us If you want to exercise your rights under this Notice or if you wish to communicate with us about Privacy issues or if you wish to file a complaint with us, you can write to the address below. You will not be penalized for filing a complaint with us.

Accountable Care Management Group, LLC
707 Miamisburg-Centerville Rd #406
Dayton, OH 45459

I do hereby authorize Secure Enroll Inc. and Certified Health Enrollment Services to use and disclose my Protected Health Information for the purposes identified in the above statement. This authorization will expire one year after my termination of all insurance coverage affiliated with these entities, or upon my written request to terminate said authorization. *Confirmation is required to proceed

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