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
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
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
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
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.
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
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