Download Paciente Existente - Wellness Alliance

Wellness Care Complete
Instrucciones Generales
 Su tiempo es valioso por lo que hemos reservado y personalizado su cita. Si por alguna razón no puede asistir a su
cita, por favor, avísenos con por lo menos 24 horas de anticipación.
 Para que el programa Wellness Care Platinum Basic funcione de la manera más eficiente, su cita se programa para
la fecha y hora indicada. Su puntualidad es indispensable.
 Favor leer las instrucciones y enviar los documentos requeridos antes de su cita por fax (787-708-6779) o vía correo
electrónica a info@prevencionpr.com. Si tiene menos de 32 años no tiene que completar el cuestionario
Coronary Risk Profile.
 Estamos localizados en Metro Office Park, Edificio Millennium Park Plaza # 15, Second Street, Suite 540, Guaynabo
PR.
 Durante su evaluación se estarán realizando diferentes pruebas que requieren su concentración por lo que le
recomendamos que no venga acompañado(a) por niños.
 Traiga su tarjeta de identificación de su Plan Médico o la autorización de la empresa para la cual labora, si aplica.
 El día del examen debe estar en ayuna desde las 12:00 a.m. de la noche anterior. (No tome alimentos ni bebidas
después de las 12:00 de la medianoche)
 Traiga sus medicamentos recetados para que los tome cuando se le indique.
 A los caballeros mayores de 40 años se le realizará la prueba de PSA sanguíneo y un examen rectal.
 Para su seguridad y debido a la exposición de radiación, no se realizará la placa de pecho a las féminas que estén
embarazadas o sospechen estarlo, o si están lactando.
 Si tiene preguntas o dudas, o necesita información adicional, llámenos al 787-708-6777 ó 787-708-6778.
CONSENTIMIENTO / CONSENT
WELLNESS CARE PLATINUM BASIC
Yo ______________________________________ autorizo a Wellness Alliance a realizar
las siguientes pruebas como parte de la Evaluación Preventiva Anual. /
I _________________________________________ authorize Wellness Alliance to perform
the following tests as part of the Annual Preventive Evaluation.
 Laboratorios/Laboratories
 Evaluación de Próstata (hombres mayores de 40 años) con PSA / Prostate
Assessment (male > 40 years old)
 Electrocardiograma/ Electrocardiogram
 Placa de Pecho / Chest X Ray
 Cernimiento Audivito / Hearing Screening
 Cernimiento Visual / Visual Screening
 Espirometria (Función Pulmonar) / Spirometry (Pulmonary function Test)
 Cernimiento de Salud Mental / Mental Health Screening
 Perfil de Riesgo Coronario / Coronary Risk Profile
 Examen Físico – Physical Examination
 Certifico que se me entregó y leí la Ley de Privacidad del Paciente, conocida por sus
abreviaturas, Ley HIPPA. / I certify that I received and read the Patient Privacy Act,
known by its initials, HIPAA Law.
___________________________________________________________________
Firma
Fecha
La alianza de salud para su empresa
Millennium Park Plaza, #15 Second ST, suite 540 Guaynabo, PR 00968
PO Box 9419 San Juan, Puerto Rico, 00908
www.wellnessalliancepr.com
Breakfast Menu for ____________
Favor escoger una de las siguientes alternativas / Please choose one of the
following:
Alternativa 1 /Alternative 1
Tortilla (sin colesterol) / Omelet (Cholesterol Free)
 Jamón (99% libre de grasa) / Ham (99% Fat free)
 Queso (libre de grasa) . Cheese (Fat Free)
 Cebolla / Onion
 Pimientos / Pepper
Alternativa 2 / Alternative 2
Cereal / Cereal
Ambas alternativas con:
Frutas /Fruits
Café / Coffee Chocolate caliente / Hot Chocolate or Té /Tea
Jugo de china / Orange Juice
La alianza de salud para su empresa
Millennium Park Plaza, #15 Second ST, suite 540 Guaynabo, PR 00968
PO Box 9419 San Juan, Puerto Rico, 00908
www.wellnessalliancepr.com
PERFIL DE RIESGO CORONARIO / CORONARY RISK PROFILE
Por favor, escriba en letra de molde. / PLEASE PRINT
Apellidos
Last Name(s)
Fecha De Nacimiento
Date of Birth
Raza
Race
Caucásica / White
Asiático / Asian
Nombre
Name
Sexo
Gender
Afro-americana / African-American
Nativo americano / Native American
M
Inicial
Middle Initial
Peso
Weight
F
Estatura
Height
Hispano / Hispanic
Otro / Other:
Dirección
Ciudad
City
Estado
State
# Teléfono del Trabajo
Work Telephone #
# Teléfono del Hogar
Home Telephone #
Dirección De Correo Electrónico
E-Mail Address
Código Postal
Zip Code
HISTORIAL DE SALUD / HEALTH HISTORY
Familiar / Family: Haga una marca en cualquier problema de salud que ha tenido su familia (padre, madres, hermano o hermana).
Make a mark on any health problems found in your family (father, mother, brother or sister)
Diabetes
Obesidad / Obesity
Infarto antes de los 65 años de edad
Stroke before the age of 65
Colesterol alto / High cholesterol
Presión arterial alta / High blood pressure
Enfermedad coronaria, infarto cardiaco o cirugía coronaria antes de los
55 años de edad para varones, 65 años de edad para las féminas
Coronary heart disease, heart attack or coronary surgery before the age
of 55 for men, 65 for women
Historial de Salud Personal / Personal Health History:
Haga una marca en cualquier problema de salud que su médico le haya dicho que tiene. / Make a mark on any health problem your physician has told you that you have.
Enfermedad coronaria, angina (dolor de pecho), ataque cardiaco, cirugía
coronaria de desviación arterial, marcapasos, desfibrilador, colocación de stent,
o angioplastia
Fallo cardiaco congestivo
Coronary heart disease, angina (chest pain), a heart attack, coronary artery bypass
surgery, pacemaker, defibrillator, stent placement or angioplasty
Arritmia (latidos rápidos e irregulares del corazón
Atrial fibrillation (rapid, irregular heartbeat)
Síncope o flujo sanguíneo restringido a la cabeza
Stroke or restricted blood flow to head
Ataques isquémicos pasajeros (señales de aviso de síncope)
Transient ischemic attack (stroke warning signs)
Dolor en la pantorrilla mientras camina que cesa con descanso
Pain in calf when walking that stops with rest
Colesterol sanguíneo alto (240+ mg/dL o 6.2 mmol/L)
High blood cholesterol (240+ mg/dL o 6.2 mmol/L)
Presión arterial alta (140/90+)
High blood pressure (140/90+)
Diabetes
Diabetes
Bronquitis crónica o enfisema (COPD)
Chronic bronchitis or emphysema (COPD)
Tos crónica (3 semanas o más)
Chronic cough (3 weeks or more)
Asma (jadeo, tos, dificultad para respirar)
Asthma (wheezing, coughing, difficulty breathing)
Corto de respiración al ejercitarse
Shortness of breath with exertion
Congestive heart failure
Medicamentos / Medications. Marque cualesquiera medicinas que toma regularmente. / Mark any medicines you take regularly.
Nitroglicerina, para el dolor de pecho / Nitroglycerine, for chest pain
Medicina para la presión alta / Blood pressure medicine
Aspirina / Aspirin
Anticoagulante (diluyente sanguíneo) / Anticoagulant (blood thinner)
Medicina para bajar el colesterol / Cholesterol-lowering medicine
Medicina para la Diabetes / Diabetes medicine
Estrógeno, hormonas femeninas / Estrogen, feminine hormones
Medicina para el asma, COPD / Asthma, COPD medicine
Otro / Other:
Historial de Fumador / Smoking History
Indique sus prácticas actuales de fumador / Indicate your present smoking practices.
Nunca ha fumado / Never smoked
Dejó de fumar hace más de un año / Quit smoking more than a year ago
Fuma cigarrillos actualmente / Currently smoke cigarettes
Dejó de fumar durante el pasado año / Quit smoking within the last year
Fuma una pipa o cigarro solamente / Smoke a pipe or cigar only
Fumador de segunda mano / Secondhand smoke:
¿Está usted expuesto a humo de segunda mano regularmente en el hogar o en el trabajo?
Are ;you exposed to secondhand smoke regularly at home or at work?
Yes
No
Sí
No
Actividad Física / Physical Activity
Ejercicio aeróbico: ¿Cuántas días a la semana acumula usted por lo menos 30
minutos de actividad física como caminar ligero, ciclismo, trotar, nadar, jardinería
activa o deportes activos?
Ningún ejercicio regular
Un día
Dos días
De tres a cuatro días
Cinco días
Three to four
Actividades moderadas: ¿Cuánto tiempo pasa usted semanalmente en actividades
moderadas (caminar ligero, correr bicicleta hasta 10 mph, baile aeróbico, etc.)?
Ninguna actividad regular
½ hora
1 hora
2 horas
3-4 horas
5 horas o más
Actividades vigorosas: ¿Cuánto tiempo pasa usted semanalmente en actividades
vigorosas (correr, correr bicicleta hasta 12 mph o más, deportes activos)?
Ninguna actividad regular
½ hora
1 hora
2 horas
3-4 horas
Perfil de Riesgo Coronario / Coronary Risk Profile
Aerobic exercise: How many days each week do you accumulate at least 30
minutes of physical activity such as brisk walking, cycling, jogging, swimming, active
gardening or active sports?
No regular exercise
One
Two
5 horas o más
Five or more
Moderate Activities.: How much time each week do you spend doing moderate
activities (e.g. brisk walking, bike up to10 mph, aerobic dance)?
No regular activity
½ hour
1 hour
2 hours
3-4 hours
5 or more hours
Vigorous Activities.: How much time each week do you spend doing vigorous
activities (e.g. running, bike up to12 or more mph, active sports)?
No regular activity
½ hour
1 hour
2 hours
3-4 hours
5 or more hours
Página / Page 1
Restricción de ejercicio.
¿Le ha restringido un médico la actividad por razones de salud?
Sí
No
Exercise Restriction.
Has a doctor restricted your activity for health reasons?
Yes
No
Hábitos alimenticios / Eating Practices
Comidas regulares.
¿Omite el desayuno u otras comidas regularmente?
Sí
Regular meals.
Do you often skip breakfast or other meals?
No
Panes/granos. ¿Cuántas porciones de panes o cereales integrales consume usted
diariamente (porción = 1 rebanada de pan; 1 taza de cereal seco; ½ taza de cereal
cocido; ½ taza de arroz integral)?
Ninguna
Una
Dos
Tres
Cuatro
5 o más
Yes
No
Breads/Grains. How many servings of whole grain bread or cereals do you eat daily
(serving = 1 slice bread; 1 cup dry cereal; ½ cup cooked cereal; ½ cup of brown rice?
None
One
Two
Three
Four
5 or more
Frutas. ¿Cuántas porciones de frutas consume usted diariamente (porción = 1 taza
fresca; ½ taza cocidas; 6 onzas de jugo)?
Ninguna
Una
Dos
Tres
Cuatro o más
Fruits. How many servings of fruits do you eat daily (serving = 1 cup fresh; ½ cup
cooked; 6 oz of juice?
None
One
Two
Three
Four or more
Vegetales. ¿Cuántas porciones de vegetales consume usted diariamente (porción =
1 taza crudos; ½ taza cocidos; 6 onzas de jugo de vegetales; 1 ensalada mediana)?
Ninguna
Una
Dos
Tres
Cuatro
5 o más
Vegetables. How many servings of vegetables do you eat daily (serving = 1 cup raw;
½ cup cooked; 6 oz of vegetable juice; 1 medium salad)?
None
One
Two
Three
Four
5 or more
Alimentos refinados. ¿Cuántas veces al día consume usted alimentos altamente
refinados y meriendas típicas (bebidas carbonatadas, chips, papitas fritas, postres,
galletas, bizcocho u otros dulces)?
Ninguna
Una
Dos
Tres
Cuatro
5 o más
Refined Foods. How times a day do you eat highly refined foods and typical snacks
(soda pop, chips, fries, pastry, cookies, cake or other sweets)?
None
One
Two
Three
Four
5 or more
Grasas. Marque cualquiera de las siguientes grasas o alimentos altos en grasas que
usted típicamente consume (incluyendo los que usa al cocinar).
Mantequilla
Margarina en barra
Margarina libre de ácidos trans-grasos
Aderezo para ensalada en aceite o mayonesa
Aceites vegetales (i.e., oliva, canola, soya)
Manteca o jugo de la carne
Nueces, semillas o mantequilla no hidrogenada de maní
Aceitunas o aguacate
Fats. Mark any of the fats or high fat foods below that you typically eat (including
those used in cooking?
Butter
Stick margarine
Trans fatty acid free margarine
Oil-based salad dressing or mayonnaise
Vegetable oils (e.g., olive, canola, soy)
Shortening, lard or meat drippings
Nuts, seeds or non-hydrogenated nut butters
Olives or avocados
Carnes. ¿Qué clase de carne consume usted usualmente?
Carnes rojas mayormente incluyendo bistec, hamburguesa, hot dog, tocineta,
salchichas o pollo frito.
Rara vez carne roja o limitado a cortes magros, o come pollo sin piel o pescado
Rara vez come carne, come alimentos mayormente sin carne (alimentos
vegetarianos de proteína)
Huevos. ¿Cuántas yemas de huevo consume usted semanalmente (incluyendo las
que usa al cocinar)?
Ninguna
Una
Dos
Tres
Cuatro
5 o más
Meats. What type of meat do you usually eat?
Primarily read meats including steak, hamburger, hot dog, bacon, sausage or fried
chicken
Seldom eat red meat or limit it to only lean cuts, or eat skinless poultry or fish
Nueces y semillas. ¿Cuántas porciones de nueces, semillas o mantequilla no
hidrogenada de maní consume usted semanalmente (1 porción = 1 oz de nueces o
semillas o 2 cucharadas de mantequilla de nueces)?
Ninguna
Una
Dos
Tres
Cuatro
5 o más
Productos lácteos. ¿Qué clase de productos lácteos usa usted usualmente?
leche regular, yogur, queso, crema agria
solamente productos lácteos sin grasa (o no lácteos)
consumo ambos
Seldom each any meats, eat primarily meatless entrees (vegetarian protein foods)
Eggs. How many egg yolks do you each week (including those used in cooking)?
None
One
Two
Three
Four
5 or more
Nuts and Seeds. How many servings of nuts, seeds or non-hydrogenated nut butters
do you eat weekly (serving = 1 oz of nuts or seeds, o 2 tablespoons of nut butter)?
None
One
Two
Three
Four
5 or more
Dairy Products. What type of dairy products do you usually use?
regular milk, yogurt, cheese, sour cream
only non-fat dairy products (or non-dairy
use both of the above
Legumbres. ¿Cuántas porciones (2/3 de taza) de habichuelas, guisantes o
habichuelas de soya consume usted semanalmente?
Ninguna o menos de 1
1ó2
3 o más
Legumes. How may servings (2/3 cup) of beans, split peas or soybeans do you eat
weekly?
None or less than one
1 or 2
3 or more
Sal. ¿Añade usted a menudo sal a su comida en la mesa o come alimentos salados
(pepinillos, salsa soya, papitas) frecuentemente?
Sí
No
Salt. Do you often add salt to your food at the table and frequently eat salty foods
(pickles, soy sauce, chips)?
Yes
No
Bebidas con cafeína. ¿Cuántas bebidas con cafeína toma usted diariamente (café,
té, colas)?
Ninguna
Una
Dos
Tres
Cuatro
5 o más
Caffeine Drinks. How many caffeinated beverages do you drink daily (coffee, tea,
cola drinks)?
None
One
Two
Three
Four
5 or more
Agua. ¿Cuántos vasos de agua toma usted diariamente?
Menos de 3
3a5
6a7
Water. How many glasses of water do you drink daily?
Less than 3
3 to 5
6 to 7
8 o más
Comidas de restaurantes.
Cuando come afuera, ¿qué tipo de comidas ordena usted típicamente?
Comidas altas en grasa: establecimientos de comida rápida, biftec, pollo frito,
alimentos con salsas espesas, crema agria, queso, y postres suculentos
O comidas más saludables: bajas en grasa y más vegetales, granos y frutas
mayormente comidas altas en grasas
mayormente comidas más saludables o rara vez como afuera
como más o menos la misma cantidad de ambas
Alcohol. ¿Cuántos bebidas alcohólicas toma usted en una semana?
(1 trago = 12 oz de cerveza, 5.5 oz de vino o 1.5 oz de licor)?
rara vez o nunca tomo esas bebidas
hasta 7
hasta 14
Peso. Indique cualquier cambio de peso desde que tenía 21 años de edad
No he subido de peso o he aumentado menos de10 libras.
He aumentado de 10 a 19 libras.
He aumentado de 20 a 29 libras.
He aumentado de 30 libras o más.
Perfil de Riesgo Coronario / Coronary Risk Profile
8 or more
Restaurant Meals.
When you eat out, what type of meals do you typically order?
High fat meals: fast food, steak, fried chicken, foods with rich sauces, sour cream,
cheese, and rich desserts
Or healthier meals: lower in fat and more vegetables, grains, and fruits
mostly high fat meals
mostly healthier meals or seldom eat out
eat both kinds about the same
Alcohol. How many alcohol containing beverages do you drink in a typical week?
(1 drink = 12 oz of beer, 5.5 oz of wine or 1.5 of liquor)
más de 14
rarely drink these beverages
up to 7
up to 14
more than 14
Weight. Indicate any change in weight since you were about 21 years old.
I have not gained weight or gained less tan 10 pounds.
I have gained 10 to 19 pounds.
I have gained 20 to 29 pounds.
I have gained 30 pounds or more.
Página / Page 2
Factores Mentales y Sociales / Mental and Social Factors
Las emociones y relaciones pueden tener un efecto sobre la salud cardiaca. Indique su situación.
Emotions and relationships can have an effect on heart health. Indicate your situation.
Triste. ¿Se ha sentido triste e infeliz gran parte del tiempo
últimamente?
Sí
No
Unhappy. Have you felt sad and unhappy much of the time lately?
Yes
No
Coraje. ¿Se ha sentido frustrado, molesto o con coraje gran parte
del tiempo últimamente?
Sí
No
Anger. Have you felt frustrated, upset or angry much of the time
lately?
Yes
No
Apoyo social. ¿Tiene usted familiares o amigos a quienes les habla
y con quienes socializa frecuentemente?
Sí
No
Social Support. Do you have family and friends you talk to and
socialize with frequently?
Yes
No
Comunidad. ¿Se reúne usted regularmente con un grupo que le da
apoyo, alivio y significado en su vida?
Sí
No
Community. Do you meet regularly with a group that give you
support, comfort, and meaning in your life?
Yes
No
Sueño. ¿Duerme por lo general menos de 7 a 8 horas diariamente?
Sí
No
Sleep. Do you usually get less than 7 to 8 hours of sleep daily?
Yes
No
Agotamiento. ¿Se siente usted cansado, agotado y exhausto gran
parte del tiempo?
Sí
No
Fatigue. Do you feel tired, worn out, and exhausted much of the
time?
Yes
No
Mujeres solamente. Marque cualquier condición que aplique.
Actualmente embarazada
Llegué a la menopausia.
Women only. Mark any condition that applies.
Currently pregnant
Reached menopause
Preparación. ¿Está usted preparado para hacer cambios de estilo de vida para
mejorar su salud en las siguientes áreas?
(Refiérase a las cinco descripciones listadas.)
1 Ningún interés actual en hacer cualquier cambio de estilo de vida
2 Considerando hacer un cambio de estilo de vida
3 Haciendo planes para lograr este cambio
4 Comencé recientemente a implementar este cambio.
5 Lo he estado haciendo por 6 meses o más.
Readiness. Are you ready to make lifestyle changes to improve your health in the
following areas?
(Refer to the five descriptions shown.)
1 No present interest in making any lifestyle change
2 Thinking about making a lifestyle changes
3 Making plants to achieve this change
4 Recently started implementing this change.
5 Have been doing this for 6 months or more.
1
2
3
4
5 Comer diariamente alimentos saludables para el corazón
1
2
3
4
5 Eat heart-healthy meals daily
1
2
3
4
5 Dejar de fumar o continuar siendo un no fumador
1
2
3
4
5 Quit smoking or remain a non-smoker
1
2
3
4
5 30 minutos o más de actividad física, 3-4 + días a la semana
1
2
3
4
5 30 minutes or more of physical activity, 3-4+ days/per week
1
2
3
4
5 Lograr/mantener un peso saludable
1
2
3
4
5 Achieve/maintain a healthy weight
Fecha / Date:
Perfil de Riesgo Coronario / Coronary Risk Profile
Página / Page 3
AUTORIZACION
Yo, _______________________, autorizo a Wellness Alliance a
enviar los resultados de la evaluación médica preventiva al correo
electrónico ___________________________________ de darse
alguna de las siguientes situaciones:
 Resultados alterados que requieren atención inmediata
 No poder asistir a mi cita de Entrevista Final luego de ser contactado
por el personal de Wellness Alliance
 De no recibir contestación para coordinar su entrevista final luego de
ser contactado en más de tres ocasiones.
______________________
Firma
______________
Fecha
Número Récord: _________________

De no tener correo electrónico se enviaran sus resultados por correo postal.
La alianza de salud para su empresa
Millennium Park Plaza, #15 Second ST, suite 540 Guaynabo, PR 00968-1743
787-708-6777
www.prevencionpr.com
NOTICE OF PRIVACY PRACTICES FOR THE PROTECTION
OF PROTECTED HEALTH INFORMATION THAT IDENTIFIES THE INDIVIDUAL
This notice describes how your protected health Information might be used and disclosed and how You
can obtain access to the same. Please, review it carefully.
OUR LEGAL RESPONSIBILITY
Wellness Alliance is committed to safeguard your Protected Health Information.
We are required by Law to maintain the privacy and confidentiality of your
protected health information (PHI) and to provide you with this notice of our
legal duties and privacy practices with respect to protected health information.
This notice will be effective on December 1, 2008, and will remain effective until
we revise it. WELLNESS ALLIANCE will abide by the terms the notice currently
in effect.
Wellness Alliance reserves the right to change our privacy practices and the
terms of this notice. Before we make a significant change in our privacy
practices, we will change this notice and send an updated notice to our active
subscribers.
Protected Health Information is information that can identify you (name, last
name, social security number); including demographic information (like address,
zip code), obtained from you through a request or other document in order to
obtain a service, created and received by a health care provider, a medical
plan, intermediaries who submit claims for medical services, business
associates, and that is related to (1) your health and physical or mental
condition, past, present, or future; (2) the provision of medical care to you, or (3)
past, present, or future payments for the provision of such medical care. In this
Notice, this information will be called protected health information. This Notice
of Privacy Practices has been written and amended so that it will comply with
HIPAA Privacy Regulations. Any term not defined in this Notice will have the
same meaning that it has in the HIPAA Privacy Regulation.
Main Uses and Disclosures of Protected Health Information
In order to perform our duties as insurance or benefit administrator, we may use
or disclose information for medical treatment, payment of medical services, and
health care operations; for example:
Treatment. For the provision, coordination, or supervision of your medical care,
and other related services. For example, the plan may disclose medical
information to your health care provider for treatment, if so requested.
Payment .To collect or provide payment for medical care, including collections
and claims handling. For example, the plan may use or disclose protected
health information in order to pay claims for health services rendered, or to
provide eligibility information to your health care provider when you receive
treatment.
Health Care Operations. For legal purposes and audit processes, including
fraud and abuse detention and compliance, as well as the planning and
development of businesses and administrative activities and management of
businesses. We may use or disclose medical information to another entity
related to you and that is also subject to the federal or local rules.
Gathered Information
Wellness Alliance has the commitment to limit the information that we gathered
to the strictly necessary for the administration of your insurance coverage or
benefit. Within our functions of administration, we gathered personal information
that you provide in application forms and other documents, transactions with us
or with our affiliated companies, credit agencies, and information of health care
providers, for example post service claims.
Covered Entities
To perform our duties as a health care service provider, Wellness Alliance may
use or disclose protected health information.
Business Associates
We contract with persons and organizations (business associates) so they can
perform certain functions in our name, or to provide certain types of services. In
order to perform these functions or provide these services, business associates
may receive, create, maintain, use, or disclose protected health information, but
only after they agree in writing to properly safeguard such information. Among
the examples of business associates are institutions that offer claims
processing, certain accounting activities (CPA), and technical support for
medically oriented computer software.
Other Covered Entities
We may use or disclose your protected health information in order to assist
health care providers with the treatment they provide to you, or with payment
activities concerning you. For example, we may disclose or share your
protected health information in order to coordinate benefits. We may disclose
your protected health information to a health care professional if he or she
provides you with treatment.
Other Possible Uses and/or Disclosures of Your Protected Health
Information
Required by Law. We may use or disclose your protected health information
whenever Federal, State, or Local Laws require its use or disclosure. In this
Notice, the phrase “as required by Law” is defined the same as it is defined in
HIPAA Privacy Standards.
Public Health Activities. We may use or disclose your protected health
information for public health activities, including the statistical report on illnesses
and vital information, among others.
Health Oversight Activities. We may use or disclose your protected health
information to those government agencies that regulate health care related
activities.
Food and Drug Administration (FDA). We may use or disclose your protected
health information to the FDA in order to prevent to the health or national
security in relation to adverse events related to food, supplements, products
and product defects, among others.
Abuse Or Neglect. We may use or disclose your protected health information to
a government official authorized to receive reports of abuse or neglect against
minors or adults or domestic violence situations.
Legal Proceedings. We may use or disclose your protected health information
during the course of any judicial or administrative proceedings: (i) in response
to an order of a court or administrative tribunal (provided that the covered entity
discloses only the protected health information expressly authorized by such
order); or (ii) in response to a subpoena, discovery request, or other lawful
process.
Law Enforcement Officials. We may use or disclose your protected health
information to law enforcement officials. We may use or disclose your protected
health information for research purposes.
In addition to: Correctional institutions in the case of inmates; as authorized by
laws relating to workers’ compensation (Corporacion del Fondo del Seguro del
Estado); disaster relief efforts, so that your family may be provided with
information about your health condition, and your location.
Other persons participating in your health care. Unless request a restriction (in
accordance with the procedure described later in this Notice of Privacy
Practices, under “Right to request a restriction”) we may disclose limited
protected health information to a friend or family member who is involved with
your care, or who are responsible for payment of medical services. If you are
not in person, if you are disabled, or it is an emergency, we will use our
professional judgment in the disclosure of information that we understand will
be in your better interest.
Disclosures to an Authorized Representative. We will disclose your protected
health information to a person designated by you as your authorized
representative, and who qualifies for this designation in accordance with
applicable laws of the Commonwealth of Puerto Rico. However, before we
disclose protected health information to your authorized representative, you
must provide us with a written document designating this person as such, along
with any other support documents (like a power of attorney).
Even when you designate an authorized representative, HIPAA Privacy
Regulations allow us not to treat this person as your authorized representative
if, in our professional judgment, conclude that: (i) you have been or may be
subject to domestic violence, abuse, or neglect by such person; (ii) treating
such person as your authorized representative could endanger you, or (iii) we,
in the exercise of professional judgment, decide that it is not in your best
interest to treat this person as your authorized representative.
With your authorization:
You may authorize us in writing, to use or disclose your protected health
information to other persons, for any other purpose. The authorization must be
signed and dated by you, it must indicate the person or entity authorized to
receive the information, a short description of the information been disclosed,
and expiration date for the authorization, which will not exceed two years from
the date on which the document is signed. You have the right to revoke the
authorization in writing, and the revocation will be in effect for future uses and
disclosures of your protected health information. Nevertheless, your revocation
will not apply to information that we have already used or disclosed. Unless you
submit a written authorization, we may not use or disclose your protected health
information for any other reason not described in this Notice.
RIGHT TO PRIVACY
You have the following rights regarding your protected health information.
Right to Request a Restriction
You have the right to request a restriction to the protected health information
that we maintain at Wellness Alliance, and that we use or disclose for
treatment, payment, or health care operations. Nevertheless, we are not
required by Law to agree to any restriction that you request. If we agree to a
restriction, we will comply with the same, unless the information is needed in
order to provide you with emergency treatment. You may request a restriction
by completing a request form, available at our service centers and through our
Internet site. This form must be signed and approved by an authorized official.
Right to Confidential Communications
You may request that we communicate with you concerning your protected
health information using an alternate method or physical location. For example,
you may request that we contact you only at your work address, or use only
your work phone number. You may request confidential communications by
completing a request form, available at our service centers and through our
Internet site.
Right to Access
You have the right to inspect and copy your personal, financial, insurance, or
health information, within the limits and exceptions provided by law. In order to
access your information, you must submit a written request to the Wellness
Alliance’s Security and Privacy Department. You may obtain the request form at
our service centers or through our Internet site. The first report that you request
will be free. We reserve the right to charge a fee for subsequent copies.
We may deny access to inspect or copy your protected health information under
certain limited circumstances. If we deny you access to your information, you
may request a review of our denial. In order to request a review, you must
contact our Office at the address on this Notice of Privacy Practices. An
authorized official will review your request, and denial.
Right to Amend
If you believe that your protected health information, and that we keep in our
files and/or systems, is incomplete or incorrect, you may request that we amend
it. You may request to amend your protected health information by completing a
request form, available at our service centers or through our Internet site. Your
request must include an explanation or evidence to justify an amendment. Your
request may be denied. If your request is denied, we will provide you with a
written explanation for this denial.
Right to an Accounting of Disclosures
You have the right to request an accounting of certain disclosures of your
protected health information made by MCS, for events not related to medical
treatment, payment for medical services, health care operations, or in
compliance with your authorization. You may request an accounting of
disclosures by completing the request form available at our service centers or
through our Internet site.
Right to a Printed Copy of this Notice
You have the right to obtain a paper copy of this Notice of Privacy Practices at
your request, even after agreeing to receive a copy of the same in electronic
form.
COMPLAINTS
If you understand that we have incurred in any violation of your privacy rights,
or if you disagree with our decisions with regards to access to your protected
health information, you have the right to submit a complaint to the address at
the end of this Notice. Likewise, you may file a complaint with the Secretary of
Health and Human Services (DHHS), at the following address: Region II, Office
for Civil Rights, US Department of Health and Human Services (DHHS) Jacob
Javits Bldg., 26 Federal Plaza, Suite 3312, New York, 10278; telephone: 1-866627-7748, or the Internet address: www.hhs.gov/ocr/hipaa. Your complaint
should include: (1) the name of the covered entity you are filing a complaint
against; (2) brief description of the alleged violation, and (3) file the complaint
within 180 days of when the complainant knew of should have known that the
act or omission complained of occurred.
At Wellness Alliance, we believe in the privacy of our clients protected health
information. We will not penalize nor retaliate against you for filing a complaint
with the Department of Health and Human Services, or with Wellness Alliance.
CONTACT INFORMATION FOR WELLNESS ALLIANCE
You may request additional information about this Notice of Privacy Practices,
or file a complaint with Wellness Alliance at the following address:
WELLNESS ALLIANCE
Attention: Privacy Officer
Millennium Park Plaza • 15 2nd Street • Suite 540
Guaynabo, PR 00968
787-708-6777
www.wellnessalliancepr.com
www.prevencionpr.com
EFFECTIVE DAY
This Notice of Privacy Practices is effective on December 1, 2008.