1. health and fitness
2. disease
3. cancer

RANDI J. KATZ, D.O.
RAGHU K. KUNAMNENI, M.D.
KENNETH D. NAHUM, D.O., F.A.C.P.
MONIR SOLIMAN, M.D.
ETHAN WASSERMAN, M.D.
PATIENT PORTAL
Dear Patients,
We have been taking steps to get our patient portal open for you to view.
Currently, we are communicating with patients regarding their PT/INR results, as
well as their iron results. All patients are also able to view their blood work results
through the portal. If you are not registered for the portal, please let us know and
we will be happy to assist you.
As of Monday, March 23, 2015, we are opening the patient portal for you to
communicate with us regarding your appointments; and as of April 1, 2015, you
will be able to communicate with the office regarding medication refills. Please
bear with us as we make this transition.
Please note: We will no longer be able to draw cholesterol levels during your lab
appointment Insurance will not cover this test. This ¡s also the reason that we
cannot draw blood work ordered by other physicians. Thank you for your
understanding.
Dr. Nahum
Dr. Katz
Dr. Kunamneni
Dr. Wasserman
4632 Route 9 South, Howell. NJ 07731 • Phone: (732) 367-1535 • Fax: (732) 367-9514
1540 Route 138, Building 2, Wall, NJ 07719 • Phone: (732) 280-9685 • Fax: (732) 367-9514
9 Hospital Drive, Suite A17, Toms River, NJ 08755 • Phone: (732) 279-6401 • Fax: (732) 367-9514
RANDI J. KATZ, D.O.
RAGHU K. KUNAMNENI, M.D.
KENNETH D. NAHUM, D.O., F.A.C.P.
MONIR SOLIMAN, M.D.
ETHAN WASSERMAN, M.D.
Date:__/__/____
Last Name:
First Name:
Address:
MI:
Phone:
Primary Care
Physician:
Work Phone:
Ext:
Social Security#:
Referred by:
(street name & number)
Gender:
M
F
(city)
(state/zip)
Employer:
DOB:__/__/__
Occupation:
Marital
Status:
S
M
D
W
Pharmacy:
INSURANCE INFORMATION
Primary
Insurance:
E-mail address:
Secondary
Insurance:
ID#:
ID#:
Group #:
Group #:
Name of Insured:
Name of Insured:
Insured DOB:__/__/____
Insured DOB:__/__/____
Insured Social Security #:
Insured Social Security #:
EMERGENCY CONTACT:
Name:
Phone #:
Address:
Relationship to Patient:
City:
State:
Zip:
GUARANTOR (PERSON RESPONSIBLE FOR BILL) INFORMATION:
Last Name:
First Name:
MI:
Relationship to Patient:
I understand that I am responsible for all financial obligations of health services and for reimbursement and
payment of claims from my insurance company. If for any reason the account should become delinquent, I
agree to pay for all billing charges, interest charges, collection costs and reasonable legal fees.
Date:__/__/____
Parent or Guardian
Name:
Age:
DOB__/__/____ DOB__/__/____
MEDICAL HISTORY
Allergies to medication? ( )
Yes ( )
No
If “Yes”, list medications:
Allergies to:
IODINE
SULFA
Do you currently have problems in any of the following areas?
Anemia (low, weak blood)
Arthritis / Rheumatism
Asthma
Bleeding Tendency / Unusual Bruising
Bowel Disorders / Colitis / Crohns
Cancer / Tumors
Diabetes
Gallbladder Trouble / Gallstones
High Blood Pressure / Hypertension
Heart Disease
Hepatitis
Skin (Warts, Skin Cancer, Unusual Moles)
Neurological Problems
Respiratory (Recurrent Pneumonia, Bronchitis, Emphysema)
If “YES” to any of the above, please provide details here:
SHELLFISH
Yes
No
FAMILY HISTORY: (If “Yes”, Indicate relationship to pt.): M=mother,F=father,S=sibling,GP=grandparent
YES NO REL.
YES
NO
REL.
DISEASE
DISEASE
High Blood Pressure
Heart Disease
Cancer
Gastrointestinal Problems
(
(
(
(
)
)
)
)
(
(
(
(
)
)
)
)
(
(
(
(
)
)
)
)
(
(
(
(
)
)
)
)
Anemia
Bleeding Disorder
Diabetes
( )
( )
( )
( )
( )
( )
SOCIAL HISTORY:
Do you drink alcohol?
Do you smoke?
Cultural / language barriers?
Advanced directives?
Physician’s signature:
( )
( )
( )
occasional
(
½ pack-less/day
)
1/day
( )
(
)
2-3/day
1pack/day
( ) 4+/day
( ) 1+pack/day
Date__/__/____
RANDI J. KATZ, D.O.
RAGHU K. KUNAMNENI, M.D.
KENNETH D. NAHUM, D.O., F.A.C.P.
MONIR SOLIMAN, M.D.
ETHAN WASSERMAN, M.D.
ASSIGNMENT AGREEMENT
Insured’s Name:
Patient’s Name:
Insurance:
Policy Number:
“I request that payment of authorized Medicare and/or my insurance benefits be made on my behalf
to
Dr. Nahum, D.O. for any services furnished to me or by my physician.”
“I authorize any holder of medical information about me to release to the Health Care Financing
Administration and its agents or my insurance company any information needed to determine these
benefits or the benefits payable for related services.”
A photocopy of this agreement shall be deemed as valid as the original.
“I understand I am still responsible for non-covered charges, co-pays and deductibles.”
Insured Signature
Date
SECONDARY INSURANCE
Insured’s Name:
Patient’s Name:
Insurance:
Policy Number:
“I request that payment of authorized Medigap benefits be made either to me or on my behalf to the
provider of service and (or) supplier for any services furnished to me by that the provider of service and
(or) supplier. I authorize any holder of Medicare information about me to release to (Name of 2nd
Ins.)______________ any information needed to determine these benefits payable for related services.”
Insured Signature
Date
RANDI J. KATZ, D.O.
RAGHU K. KUNAMNENI, M.D.
KENNETH D. NAHUM, D.O., F.A.C.P.
MONIR SOLIMAN, M.D.
ETHAN WASSERMAN, M.D.
ATTENTION PATIENTS
PLEASE BE ADVISED THAT OUR OFFICE DOES SUBMIT YOUR ENCOUNTER VISITS
WITH THE PHYSICIANS TO YOUR INSURANCE COMPANY. WE RELY ON OUR
PATIENTS TO SUPPLY US WITH THE CORRECT INSURANCE INFORMATION.
WE MUST MAKE OUR PATIENTS AWARE THAT IF YOU SUPPLY OUR OFFICE WITH
THE WRONG INSURANCE INFORMATION AT THE TIME OF SERVICE OR NEGLECT
TO TELL US OF AN INSURANCE CHANGE, AND THE CLAIM IS FILED, ONCE WE ARE
GIVEN THE CORRECT INSURANCE INFORMATION THE CLAIM MAY BE DENIED DUE
TO UNTIMELY FILING. IF THIS IS THE CASE, YOU MAY BE RESPONSIBLE FOR YOUR
BALANCE IN FULL.
IT IS YOUR RESPONSIBILITY TO SUPPLY OUR OFFICE WITH ALL THE CORRECT
INSURANCE INFORMATION AT THE TIME OF THE VISIT. PLEASE VERIFY WITH TITE
RECEPTIONIST. THAT WE HAVE ALL OF YOUR INFORMATION CORRECT.
I HAVE READ THE ABOVE NOTICE AND I AM AWARE THAT IF I DO NOT SUPPLY
THIS OFFICE WITH MY CORRECT BILLING INFORMATION, I MAY BE RESPONSIBLE
FOR MY BALANCE IN FULL.
PATIENT SIGNATURE
DATE
4632 Route 9 South, Howell. NJ 07731 • Phone: (732) 367-1535 • Fax: (732) 367-9514
1540 Route 138, Building 2, Wall, NJ 07719 • Phone: (732) 280-9685 • Fax: (732) 367-9514
9 Hospital Drive, Suite A17, Toms River, NJ 08755 • Phone: (732) 279-6401 • Fax: (732) 367-9514
RANDI J. KATZ, D.O.
RAGHU K. KUNAMNENI, M.D.
KENNETH D. NAHUM, D.O., F.A.C.P.
MONIR SOLIMAN, M.D.
ETHAN WASSERMAN, M.D.
Patient Name:
Date:
Please list all of your current prescription and over the counter medications.
Drug Allergies:
Current Medication
1.
2.
3.
4.
5.
6.
7.
8
9.
10.
11.
12.
13.
14.
Strength
Dose
Family History Questionnaire for Hereditary Cancer Syndromes
Patient Name: Phone: Date of Birth: Gender: M / F Ethnicity:
Email: Date Completed:
www.genedx.com/MyCancerHistory
Please complete the below questionnaire to assist your healthcare provider in determining if your personal or family history may be placing you or other
family members at increased risk to develop cancer, and if you may be eligible for genetic testing (which is often done via a blood test).
Tips: • Each row should be completed independently • Affected relatives on your mother’s side of the family should be listed in the pink boxes and
affected relatives on your father’s side of the family should be listed in the blue boxes • Age at diagnosis is the age at which the cancer was
diagnosed • Other friends and family can assess their cancer risk by going to www.genedx.com/MyCancerHistory where they can complete this same
form and share it with a healthcare professional.
Past genetic testing for cancer:
Self
Relative Result:
You
Breast and Ovarian Cancer
Immediate Blood
Relatives
Age at
Diagnosis
Parents, Siblings
or Children
Age at
Diagnosis
45
Mother
Sister
49
36
Extended Blood Relatives
(Aunts, Uncles, Grandparents, etc.)
Mother’s
Side
Age at
Diagnosis
Father’s
Side
Age at
Diagnosis
Example:
Woman with Breast Cancer at age ≤50
Maternal Aunt
46
Paternal First Cousin
50
Woman with Breast Cancer at age ≤50
Woman with Breast Cancer >50
“Triple Negative” Breast Cancer
(Estrogen Receptor (ER) negative, Progesterone
Receptor (PR) negative, HER2neu negative )
Ovarian, fallopian tube, or primary peritoneal cancer
A woman who has been diagnosed with both breast
and ovarian cancer in her lifetime (two separate
cancers)
Male breast cancer
Bilateral breast cancer (cancer in both breasts) or
two breast primaries
Please specify
Ashkenazi (Eastern/Central European) Jewish
ancestry with breast or ovarian cancer
Pancreatic or Prostate Cancer
Please specify
Colorectal and Endometrial (Uterine) Cancer
Age at
Diagnosis
Siblings or
Children
Age at
Diagnosis
Mother’s
Side
Age at
Diagnosis
Father’s
Side
Colorectal cancer or several pre-cancerous polyps
(adenomas) at an age ≤50
An individual who has been diagnosed with two
or more colon cancers (not reoccurrences, but two
separate primary cancers)
A woman who has been diagnosed with
endometrial (uterine) cancer at age ≤50 OR both
colorectal and endometrial (uterine) cancer
Please specify
10 or more total pre-cancerous polyps (adenomas)
in a person’s lifetime
Relatives with any of the below related cancers*
Please specify
* Related cancers include colon, endometrial (uterine), ovarian, stomach, pancreas, ureter, kidney, biliary tract, brain, small intestine, and sebaceous gland tumors/cancers
Age at
Diagnosis
NCCN Genetic Testing Criteria for Hereditary Breast and Ovarian Cancer Syndrome
Family history of a known BRCA1 or BRCA2 mutation
Personal history of breast cancer diagnosed at age 45 or younger
Personal history of breast cancer diagnosed at age 50 or younger with one of the following:
• ≥1 close blood relative(s) with breast cancer at any age
• An unknown or limited family history
• Two breast primaries, the first of which was diagnosed at age 50 or younger
Personal history of a triple negative breast cancer diagnosed at age 60 or younger
Personal history of epithelial ovarian, fallopian tube, or primary peritoneal cancer at any age
Personal history of male breast cancer at any age
Personal history of breast cancer at any age with one or more of the following:
• ≥1 close blood relative(s) with breast cancer diagnosed at age 50 or younger
• ≥2 close blood relatives with breast cancer at any age
• ≥1 close blood relative(s) with epithelial ovarian/fallopian tube/primary peritoneal cancer
• Close male blood relative with breast cancer
• ≥2 close blood relatives with pancreatic cancer and/or prostate cancer (Gleason score ≥7) at any age
• For an individual of ethnicity associated with higher mutation frequency (e.g., Ashkenazi Jewish) no additional family history may be required*
Personal history of pancreatic cancer or prostate cancer (Gleason score ≥7) at any age with ≥2 close blood relatives with breast and/or ovarian and/or pancreatic
and/or prostate cancer (Gleason score ≥7) at any age
• For pancreatic cancer, if Ashkenazi Jewish ancestry, only one additional affected relative is needed
Unaffected patient with a first or second-degree relative who meets any of the above criteria
• Testing unaffected individuals should only be considered when an appropriate affected family member is unavailable for testing
*Testing for Ashkenazi Jewish founder-specific mutation(s) should be performed first. Full sequencing may be considered if ancestry also includes non-Ashkenazi
Jewish relatives or other criteria are met.
NCCN Testing Criteria For Lynch Syndrome (also known as HNPCC) and Polyposis Syndromes
Criteria for Lynch Syndrome genetic testing
Family history of a known Lynch syndrome mutation (MLH1, MSH2, MSH6, PMS2, EPCAM)
Patient has a cancer on the Lynch syndrome tumor spectrum that demonstrates microsatellite instability (MSI-H) or absence of a mismatch repair protein via
immunohistochemistry (IHC)
Patient diagnosed with endometrial cancer at age 50 or younger
Meets Revised Bethesda Guidelines:
• Patient has a personal history of colorectal cancer AND meets one of the following:
• Patient diagnosed at age 50 or younger
• Presence of synchronous or metachronous Lynch syndrome-associated cancers, regardless of age
• Patient diagnosed at age 60 or younger with a colorectal cancer that demonstrates MSI-high histology (tumor-infiltrating lymphocytes, Crohn’s-like
lymphocytic reaction, mucinous/signet-ring differentiation, or medullary growth pattern)
• One or more first-degree relatives with a Lynch syndrome-associated cancer, with one of the cancers being diagnosed at age 50 or younger
• Two or more first- or second-degree relatives with Lynch syndrome-associated cancers, regardless of age
Meets Amsterdam Criteria:
• Patient and at least two close relatives who all have or have had a cancer associated with Lynch syndrome AND all of the following criteria must be met:
• One must be a first-degree relative of the other two;
• At least two successive generations must be affected;
• At least one of the cancers should be diagnosed at age 50 or younger;
• Familial adenomatous polyposis (FAP) should be excluded
Unaffected patient with a close relative who meets any of the above criteria
• Testing unaffected individuals when no affected family member is available should be considered; significant limitations of interpreting test results should be discussed
Criteria for Adenomatous Polyposis (APC and MUTYH) genetic testing
Family history of a known APC mutation or two (biallelic) MUTYH mutations
Personal history of a total of >10 adenomas
Personal history of a desmoid tumor
Other Polyposis Syndrome Genetic Testing Criteria
Personal or family history of multiple GI hamartomatous polyps or serrated polyps
Guidelines are current as of October, 2014. Please visit www.nccn.org for the most current guidelines.
207 Perry Parkway
Gaithersburg, MD 20877
T 1 888 729 1206 • F 1 301 710 6594
E [email protected] • www.genedx.com
© 2014 GeneDx. All rights reserved. 91855 10/2014
NOTICE OF PRIVACY PRACTICES
REGIONAL CANCER CARE ASSOCIATES LLC
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices (Notice) is provided to you by Regional Cancer Care Associates
LLC (RCCA) pursuant to the Health Insurance Portability and Accountability Act of 1996 and its
implementing regulations, as amended (HIPAA). The Notice describes how RCCA may use and
disclose your Protected Health Information to carry out treatment, payment or health care
operations and for other purposes that are permitted or required by law. It also describes your
rights to access and control your Protected Health Information. "Protected Health Information" is
information about you, including demographic information, that may identify you and that relates
to your past, present or future physical or mental health or condition; provision of health care
services to you; or the past, present or future payment for the provision of health care services to
you.
Uses and Disclosures of Protected Health Information
Your Protected Health Information may be used and disclosed by RCCA and others outside of our
offices that are involved in your care and treatment for the purposes of providing health care
services to you, to pay your health care bills, to support the operation of the physicians' practice,
and any other uses required or permitted by law.
Treatment
RCCA will use and disclose your Protected Health Information to provide, coordinate, or manage
your health care and any related services. This includes the coordination or management of your
health care with a third party. For example, RCCA may disclose your Protected Health Information
as necessary, to a home health agency that provides care to you; or your Protected Health
Information may be provided to a physician to whom you have been referred to ensure that the
physician has the necessary information to diagnose or treat you. In addition, RCCA may use a
sign-in sheet at the registration desk where you will be asked to sign your name and indicate your
physician. RCCA personnel may also call you by name in the waiting room when your physician is
ready to see you.
Additionally, RCCA may use or disclose your Protected Health Information, as necessary, to
contact you to remind you of your appointment or to provide you with information about
alternative treatments or other health care services we provide. If you request that RCCA not
make such contact with you, RCCA will observe your wishes.
1
Payment
Your Protected Health Information will be used, as necessary, to obtain payment for your health
care services. For example, obtaining approval for a procedure requiring prior authorization by
your health plan or obtaining approval for a hospital stay may require that your relevant
Protected Health Information be disclosed to the health plan to obtain approval for the procedure
or hospital admission.
Healthcare Operations
RCCA may use or disclosed, as necessary, your Protected Health Information in order to support
the business activities of the medical practice. These activities include, but are not limited to,
quality assessment activities, employee review activities, training of medical and heath care
students, licensing, and conducting or arranging for other business activities. For example, RCCA
may disclose your Protected Health Information to medical school students that see patients at
our offices.
There are some services that RCCA may provide through agreements with business associates.
When these services are contracted, RCCA may disclose your Protected Health Information to our
business associate and bill you or your health plan for the services rendered. To protect you
Protected Health Information, however, RCCA requires the business associate to appropriately
safeguard your information.
Other Uses and Disclosures That Do Not Require Prior Authorization
Required By Law: RCCA may use or disclose your Protected Health Information as required by
law, including, but not limited to, reporting of communicable diseases, incidence of cancer, burns,
seizures, gun shots, abuse, organ donations, product recalls, product failures, births/deaths, birth
defects and other required uses and disclosures.
Public Health Purposes: RCCA may disclose Protected Health Information to local, state or federal
public health authorities, as authorized or required by law, to prevent or control disease, injury or
disability; report child abuse or neglect; report domestic violence; report Food and Drug
Administration problems with products and reaction to medications; and report disease or
infection exposure.
Health Oversight Activities: RCCA may use or disclose Protected Health Information to health
agencies during the course of audits, investigations, surveys, accreditation, certification and other
proceedings necessary for oversight of (1) the health care system, (2) government benefit
programs for which health information is relevant to beneficiary eligibility, (3) entities subject to
government regulatory programs for which health information is necessary for determining
compliance with program standards; and (3) entities subject to civil rights laws for which health
information is necessary for determining compliance.
Judicial and Administrative Proceedings: RCCA may use or disclose Protected Health Information
in the course of a judicial or administrative proceeding. However, in certain instances you may be
made aware of the use or disclosure of your Protected Health Information prior to its release.
2
Law Enforcement Purposes: RCCA may use or disclose Protected Health Information to law
enforcement officials to identify or locate a suspect, fugitive, material witness, or missing person,
or, in some cases, to comply with a court order or subpoena and for other law enforcement
purposes.
Coroners or Funeral Directors: RCCA may disclose Protected Health Information to coroners or
funeral directors consistent with applicable law to carry out their duties.
Organ Procurement Organizations: Consistent with applicable law, RCCA may disclose Protected
Health Information to organ procurement organizations or other entities engaged in the
procurement, banking, or transplantation of organs for the purpose of tissue donation and
transplant.
Research: RCCA may disclose information to researchers when their research has been approved
by an Institutional Review Board (IRB). IRBs review research proposals and established
protocols to ensure the privacy of your Protected Health Information.
Public Safety: RCCA may use or disclose Protected Health Information in order to prevent or
lessen a serious and imminent threat to the health or safety of a particular person or the general
public.
Specialized Government Functions: RCCA may use or disclose Protected Health Information for
military or national security purposes. Protected Health Information of patients who are Armed
Services personnel may be used or disclosed: (1) for activities deemed necessary by the
appropriate military authorities; (2) for the purposes of a determination by the Department of
Veteran Affairs of your eligibility for benefits; or (3) to a foreign military authority if you are
member of that foreign military service. RCCA may use or disclose Protected Health Information
to authorized federal officials for national security and intelligence activities.
Workers’ Compensation: RCCA may disclose Protected Health Information to the extent
authorized and to the extent necessary to comply with laws relating to workers’ compensation or
other similar programs established by law.
Correctional Institution: RCCA may disclose Protected Health Information to corrections officials
or agents necessary for the health or safety of inmate patients or other individuals.
Family and Friends: Unless you indicate otherwise, RCCA may release your Protected Health
Information to a family member or friend identified by you, that is helping you pay for your health
care or who assists in taking care of you. In addition, RCCA may use or disclose information about
your location and general condition to notify or assist in notifying a family member, personal
representative, or another person responsible for your care.
Fundraising: RCCA may use or disclose Protected Health Information for the purposes of
communicating with you as part of RCCA’s or RCCA affiliates’ fundraising activities. You may optout of receiving such fundraising communications. RCCA may not condition treatment or
payment on your choice regarding fundraising communications.
3
Health Information Exchange: RCCA may use or disclose Protected Health Information
electronically for treatment, payment and health care operation purposes through its
participation in a health information exchange with other health care providers. You may opt-out
of the health information exchange. If so, your Protected Health Information will continue to be
used in accordance with this Notice and the law; however, your Protected Health Information will
not be made electronically available through the health information exchange.
Required Uses and Disclosures
Under the law, RCCA must make disclosures to you, upon your request, and when required by the
Secretary of the Department of Health and Human Services to investigate or determine our
compliance with the requirements of HIPAA.
De-Identified Information
Any information RCCA provides to a third party other than to our business associates or other
health care providers with a treatment relationship to you will be de-identified or stripped of any
and all personal data which could be used to identify a specific individual.
Written Authorization
Except for the purposes described above, RCCA will only use or disclose Protected Health
Information with your express written authorization and you may revoke that authorization at
any time in writing. In addition, prior to most uses or disclosures of psychotherapy notes, uses
and disclosures of Protected Health Information for marketing purposes, or disclosures that
constitute sale of Protected Health Information, RCCA is required to obtain your authorization.
Please note, however that revocations will apply only to future uses and disclosures of your
Protected Health Information.
Your Rights With Respect To Your Protected Health Information
With respect to your Protected Health Information, you have the right to the following from
RCCA:
•Restrict Use Or Disclosure - You may ask RCCA not to use or disclose any part of your
Protected Health Information for the purposes of treatment, payment or health care
operations. You may request that certain uses or disclosures of your Protected Health
Information be restricted. To do so, you must provide the request in writing using the
Request for Restriction on Use or Disclosure form available from our offices. RCCA will
determine if the information constitutes required information to carry out treatment,
payment or health care operations. If, in our sole opinion, your request does not involve
information that is required by RCCA to carry out treatment, payment or health care
operations, RCCA will accept your request for restrictions and will notify you if your request
will be honored within 30 days or as required by law.
Please note, however, that your physician is not required to agree to a restriction that you
may request, except in instances where you request that RCCA restrict use and disclosure of
your Protected Health Information to a health plan for payment or health care operation
4
purposes and such information pertains solely to a health care item or service for which you
paid “out of pocket” in full. Otherwise, if your physician believes it is in your best interest to
permit use and disclosure of your Protected Health Information, your Protected Health
Information will not be restricted. You then have the right to use another health care
professional.
•Confidential Communication Of Protected Health Information - You may request that
RCCA communicate your Protected Health Information to you by different means or to
different places. For example, you may request to receive information about your health
status in a special, private room or through correspondence sent to a private address.
Generally, RCCA communicates with patients via telephone and US mail service.
•Inspection And Copying - You may request a report containing your Protected Health
Information that has been collected by RCCA for you to inspect or copy. Such requests will
be honored within 30 days or as required by law. You will be notified in writing of RCCA’s
receipt of the request and the date upon which the information will be made available to
you.
•Amendment Or Correction - You may request that RCCA amend or correct your
Protected Health Information that has been collected by RCCA. Upon agreement, requests to
amend Protected Health Information will be honored within 60 days or as required by law.
However, RCCA may deny a requested amendment if it determines that the information is
complete, accurate, and on limited grounds. If denied, RCCA will provide the individual with
an opportunity to file a statement of disagreement and RCCA will provide documentation of
the dispute. You will be notified in writing of the action taken by RCCA.
•Accounting Of Disclosures - You may request that RCCA supply you with a listing of the
disclosures of your Protected Health Information which have been made by RCCA, except
disclosures , among others, made to you; upon your authorization; for treatment, payment
or health care operations; and for certain government functions. Such requests will be
honored within 60 days or as required by law. You will be notified in writing of the date on
which the accounting will be made available to you.
Paper Notice
Upon your request, you may receive a paper copy of this Notice from RCCA, even if you have
previously agreed to receive the Notice electronically. Copies of the Notice are available at the
registration desks in the offices of RCCA.
RCCA’s Duties To You
Generally
RCCA is required by law to maintain the privacy of Protected Health Information; to provide you
with notice of our legal duties and privacy practices with respect to Protected Health Information;
and to notify you following a breach of unsecured Protected Health Information.
Additionally, RCCA must follow the privacy practices described in this Notice.
5
Amendments
RCCA reserves the right to change the privacy practices described in this Notice at any time.
Changes to the privacy practices will apply to all Protected Health Information RCCA maintains,
even Protected Health Information created prior to the changes in the revised Notice. If RCCA
makes changes to the Notice, RCCA will immediately display the revised Notice at our offices and
on our website at regionalcancercare.org. RCCA will also provide you with a copy of the Notice
upon request.
Complaints
If you believe that your privacy rights have been violated, you may send questions or complaints
to us and/or the Secretary of the Department of Health and Human Services. RCCA will not
retaliate against you for filing such a complaint.
If you have any complaints or objections related to the matters discussed in this Notice, you may
direct your communication to the Privacy Officer at:
Regional Cancer Care Associates LLC
100 First Street, Ste. 301
Hackensack, NJ 07601
Attn: Privacy Officer
201.996.4320
Effective Date
This Notice is effective as September 23, 2013, based on revisions to privacy practices originally
implemented April 14, 2003.
Your signature below is only acknowledgement that you have received a copy of this Notice:
________________________________
Printed Name
________________________________
Signature
Date:________________________________
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