Promise Healthcare Telehealth Consent Consentimiento de Telesalud de Promise Healthcare

Promise Healthcare Telehealth Consent

I am consenting to a telehealth appointment, which I am agreeing to receive care by tele-video. I will be able to see and speak to my healthcare provider using audio/video chat. If I have health coverage, I understand Promise Healthcare will bill my health plan on my behalf and I may receive a bill for any personal balances determined by my health plan. If I do not have health coverage, I may provide my family size and income information to Promise Healthcare to determine if I qualify for discounts for this visit. If I have any questions or I need to make changes to my appointment, I may contact Promise Healthcare at 217-356-1558.

Promise Healthcare has staff who will be glad to help you apply for Medicaid benefits. They can be reached at 217-403-5457.

Consentimiento de Telesalud de Promise Healthcare

Doy mi consentimiento a una cita de telesalud, por la cual estoy de acuerdo en recibir atención médica por televideo. Yo seré capaz de ver y hablar con mi proveedor de salud utilizando conversación por audio/video. Si tengo cobertura de salud, comprendo que Promise Healthcare le facturará a mi plan de salud en mi nombre y recibiré la factura por el balance determinado por mi plan de salud. En el caso que no cuente con cobertura de salud, podré brindar la información de ingresos e información del tamaño de mi familia. Si tengo alguna pregunta o necesito reprogramar mi cita, primero debo contactarme con Promise Healthcare al número 217-356-1558.

El centro de Salud Promise Healthcare cuenta con personal el cual estará contentos en ayudarlo a aplicar a los beneficios de Medicaid. Puede contactarse con ellos al número 217-403-5457.

Aviso de privacidad de Promise Healthcare

Este aviso describe cómo su información de salud puede ser usado o revelado y cómo usted puede acceder a esta información.  Por favor, revíselo cuidadamente.

Sus derechos

Con respeto a su información de salud, usted tiene algunos derechos.  Esta sección explica sus derechos y nuestras responsabilidades para ayudarle.

Recibir una copia electrónica o una copia escrita de su registro médico

  • Usted puede pedir ver o recibir una copia (escrita o electrónica) de su registro médico y otra información de salud que tenemos con respecto a usted.  Pídanos cómo hacer esto.  Es posible que pidamos una solicitud escrita.
  • Nosotros producimos una copia o un resumen de su información de salud, típicamente dentro de treinta días de su solicitud. Podemos hacer algunos cargos que es razonable y depende de la carga actual de los servicios.

Pedirnos corregir su registro médico

  • Usted puede pedir que corrijamos su información de salud, que usted piensa está incorrecta o incompleta.  Pregúntenos cómo se puede hacer esto.
  • Es posible que neguemos su solicitud, pero le explicaremos en un formato escrito dentro de sesenta días.

Pedir comunicaciones confidenciales

  • Usted puede pedir que le contactemos en una manera específica (por ejemplo: teléfono de casa o de oficina) o enviar por correo a una dirección diferente.
  • Vamos a aceptar todas las solicitudes razonables.

Pedirnos limitar lo que usamos o compartimos

  • Usted puede pedir que no usemos o compartimos cierta información de salud para el tratamiento, los gastos, ni nuestras operaciones.

• No estamos requeridos de aceptar  su solicitud, y podemos negarlo si lo afectaría en su cuidado.

• Si usted paga para un servicio o artículo salud sin descuento, usted puede pedir que no compartamos esa información con su aseguradora de salud para el propósito de pago ni de nuestras operaciones.

• Aceptaremos aunque la ley requiere que no compartamos la información.

Solicitar una lista de con quien hemos  compartido la información

• Usted puede pedir una lista de las veces que hemos compartido su información de salud, con quien lo compartimos, y  la razón porque lo compartimos — durante los últimos seis años.

• Incluimos todas las divulgaciones excepto a las que se refieren al tratamiento, los pagos, y las operaciones de atención médica, y ciertas otras divulgaciones (lo que usted pida). Proveemos una contabilidad gratis cada año pero si pide otra dentro de doce meses, cargamos un pago que es razonable y depende de la carga actual de los servicios.

Obtener una copia de este aviso de privacidad

•Usted puede pedir una copia de este aviso en cualquier momento, incluso si usted ha accedido recibirlo electrónicamente. Se proveerá a usted rápidamente una copia escrita.

Escoger una persona que puede actuar por usted

• Si usted ha dado el poder médico a alguien o si alguien es su tutor legal, esa persona puede ejercer sus derechos y hacer opciones sobre su información de salud.

• Vamos a asegurar que la persona tiene esta autoridad y puede tomar decisiones para usted antes de que nosotros continuemos con sus solicitudes.

Presentar una queja si se siente que sus derechos han sido violados

• Usted puede quejarse si usted se siente que hemos violado sus derechos por contactarnos usando la información ubicada en la última página de este paquete.

• Usted puede presentar una queja con el Departamento de Salud y Oficina de Servicios Humanos para sus Derechos Civiles (U.S. Department of Health and Human Services Office for Civil Rights) envié una carta al 200 Independence Avenue, S.W., Washington, D.C. 20201, por llamar a 1-877-696- 6775 o puede visitar https://www.hhs.gov/hipaa/filing-a-complaint/index.html.

• No vamos a tomar represalias contra usted por presentar una queja.

Sus opciones

• Divulgar información en una situación de rescate en un desastre.

Si usted no nos puede dar su preferencia, por ejemplo si está inconsciente, podemos divulgar su información si creemos que es para su bien.  También podemos divulgar su información cuando sea necesario para disminuir una amenaza seria e inminente a su salud o seguridad.

En los siguientes casos, nunca divulgamos su información a menos que nos de su permiso por escrito:

• Propósitos de Marketing

• Venta de su información

• La mayoría de la divulgación de notas de psicoterapia

En el caso recolectar fondos:

  • Es posible que contactemos a usted por razones de colecta de fondos, pero usted nos puede decir que no le contactemos de nuevo.

Otros usos y divulgaciones

¿Cómo usamos o divulgamos su información de salud típicamente? Normalmente usamos o divulgamos su información de salud de las siguientes maneras:

Su Tratamiento

• Podemos usar su información de salud y compartirla con otros profesionales que le están tratando.

Ejemplo: Un doctor que le está tratando por una herida pregunta a otro doctor sobre su condición de salud.

• Podemos usar y compartir su información de salud para operar nuestra práctica, mejorar nuestro cuidado, y contactar a usted cuando sea necesario.               

Ejemplo: Usamos su información de salud para manejar su tratamiento y servicio.

• Podemos usar y compartir su información de salud para cobrar y recolectar pagos de seguros u otras entidades.

         Ejemplo: Damos su información a su plan de seguro para que pague por los servicios que usted recibe.

Los ejemplos usados en este Practicas de la Noticia de Privacidad “Notice of Privacy Practices” son ilustraciones solamente y no intentan ser una lista completa.

¿Hay otras maneras en las que podemos usar o compartir su información de salud?

Se permite o se requiere divulgar su información de otras maneras – normalmente de manera que contribuye al bien del público, como salud pública e investigación. Tenemos que cumplir con varias condiciones de la ley antes de que podamos divulgar su información por esas razones.  Para más información vaya a: https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html.

Ayuda con asuntos de salud y seguridad pública

• Podemos divulgar su información en los siguientes casos:

• Para prevenir enfermedades

• Para ayudar con retiradas de productos

• Presentar un informe de reacciones adversas a medicamentos

• Presentar un informe de posible abuso, abandono  o violencia doméstica

• Para prevenir or reducir una amenaza seria a la salud o seguridad de cualquier persona

Para Investigación

• Podemos usar o compartir su información para investigación médica.

Para cumplir con la ley

• Compartiremos información sobre usted si la ley federal o del estado lo requiere, incluyendo si el Departamento de Salud y Servicios Humanos quiere saber que estamos cumpliendo con la ley Federal de privacidad.

Para responder a solicitudes para donar órganos o tejidos

• Podemos compartir su información de salud con organizaciones de adquisición de órganos.

Para trabajar con un médico forense o director de la funeraria

• Podemos compartir información de salud con un médico forense o director de la funeraria cuando un individuo muere.

Para cumplir con compensación de trabajadores, los cuerpos de seguridad y otras solicitudes del gobierno

• Podemos usar o divulgar su información de salud:

• Demandas de compensación de trabajadores

• Propósitos de aplicación de la ley o con un oficial  del cuerpo de seguridad

• Con agencias  de supervisión médica para actividades autorizadas por la ley

• Para funciones especiales del gobierno como militares, seguridad nacional y servicios protectores del presidente

Responder a demandas y acciones legales

• Podemos compartir su información para cumplir con órdenes administrativas o de la corte, o para cumplir con una citación.

Ley federal y estatal para protecciones de privacidad

HIPAA generalmente no se adelanta ni anula otras leyes que dan a la gente más protección de privacidad. Si cualquier ley estatal o federal aplicable requiere que le proveamos con más protecciones de privacidad, así que tenemos que cumplir con esa ley junta con HIPAA.

Algunos tipos de información de salud pueden tener protección adicional bajo la ley federal o estatal. Por ejemplo, algunos resultados de exámenes genéticos, el historial de salud mental, resultados de exámenes de VIH/SIDA, el historial de la educación y programas de tratamiento con asistencia federal para el abuso de alcohol y drogas están sujetos a restricciones especiales de nuestro uso y divulgación bajo varias leyes.

Nuestras responsabilidades

  • La ley requiere que mantengamos la privacidad y seguridad de su información médica protegida.
  • Le dejamos saber lo antes posible si ocurre una infracción que pudiera haber comprometido la privacidad o seguridad de su información.
  • Tenemos que cumplir con los deberes y prácticas de privacidad descritos en esta noticia y darle una copia de ella.
  • No vamos a usar ni compartir su información de otra manera aparte de lo descrito aquí a menos que nos dé permiso por escrito. Si nos da permiso, puede cambiar su decisión en cualquier momento.  Déjenos saber por escrito si cambia de decisión.

Para más información ve a: https://www.hhs.gov/hipaa/for-individuals/notice-privacy-practices/index.html

Cambios a las condiciones de esta noticia

Podemos cambiar las condiciones de esta noticia y los cambios aplican a toda la información que tenemos sobre usted.  La noticia nueva estará disponsible al pedirla, en nuestra oficina y en nuestro sitio web.

Esta noticia de práctica de privacidad aplica a las siguientes organizaciones:

Esta noticia cubre los siguientes servicios de Promise Healthcare:

  • Frances Nelson Clínica Médica,
  • SmileHealthy Clínica Dental,
  • Medicaid y el Mercado de seguro médico,
  • Promise Healthcare en Urbana School Based Health Center
  • Promise Healthcare en Walnut Street, y
  • Smile Healthy PROPS, Móvil, Head Start y Educación.
  • Promise Healthcare clínica móvil  y portátil

Si tiene preguntas o le gustaría más información sobre esta noticia de práctica de privacidad, usted puede escribir o llamar al director de privacidad de Promise Healthcare:

Promise Healthcare

Privacy Officer

819 Bloomington Road

Champaign, IL 61820

www.promisehealth.org

privacy@promisehealth.org

217-356-1558

Effective Date:July 1, 2015

Updated:October 01, 2020

Notice of Privacy Practices – English

Promise Healthcare Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

When it comes to your health information, you have certain rights.  This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

  • You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you.  Ask us how to do this.  We may ask you to make the request in writing.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request.  We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

  • You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care.

• If you pay for a service or health care item out- of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.

• We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on the last page of this notice.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696- 6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html.

• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care.

• Share information in a disaster relief situation.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of behavioral health notes

In the case of fundraising:

  • We may contact you for fundraising efforts, but you can tell us not to contact you again.

Other Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways:

Treat you

• We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

• We can use and share your health information to run our practice, improve your care, and contact you when necessary.

         Example: We use health information about you to manage your treatment and services.

• We can use and share your health information to bill and get payment from health plans or other entities.

         Example: We give information about you to your health insurance plan so it will pay for your services.

The examples used in this Notice of Privacy Practices are illustrations only and not meant to be a complete list.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html.

Help with public health and safety issues

• We can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

Do research

• We can use or share your information for health research.

Comply with the law

• We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

• We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

• We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

• We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Federal law privacy protections and state law privacy protections

HIPAA generally does not preempt or override other laws that give people greater privacy protections. If any applicable state or federal law requires us to provide you with more privacy protections, then we must follow that law in addition to HIPAA.

Some types of health information may have additional protection under federal or state law. For example, some genetic test results, mental health records, HIV / AIDS test results, educational records, and federally assisted alcohol and substance abuse treatment programs are subject to special restrictions on our use and disclosure under various laws.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: https://www.hhs.gov/hipaa/for-individuals/notice-privacy-practices/index.html

Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This Notice of Privacy Practices applies to the following organizations:

This notice covers Promise Healthcare’s services which includes:

  • Frances Nelson Health Center,
  • SmileHealthy Dental Center,
  • Medicaid and Health Insurance Marketplace Outreach and Enrollment,
  • Promise Healthcare at the Urbana School Based Health Center
  • Promise Healthcare on Walnut Street
  • SmileHealthy PROPS, Mobile, Head Start & Education, and
  • Promise Healthcare mobile and portable clinical care

If you have any questions or would like further information about this Notice of Privacy Practices, you can write or call Promise Healthcare’s Privacy Officer:

Promise Healthcare

Privacy Officer

819 Bloomington Road

Champaign, IL 61820

www.promisehealth.org

privacy@promisehealth.org

217-356-1558

Effective Date:July 1, 2015.  Updated:  October 1, 2020

WHAT MAKES ME MOST PROUD OF FNHC

by Norma Coleman

HELPING THE PEOPLE WE SERVE. Sometimes when speaking with people about Frances Nelson, I’ve found that they have never even heard of it.  But when I tell them what we do and the people we serve they are often times so amazed. They are amazed about how we help people with the very basic needs in life that some of us take for granted, like having a place to live, affording a doctor, dentist or medication. Yeah, all of this makes me most proud of Frances Nelson.

Where do you envision FNHC in the future

I envision FNHC expanding to even more sites. I received a call from a patient once who moved out of state and she asked was there a FN location where she was moving.  I think that was a compliment to the type of service we had provided for her. I envision FNHC being granted to provide additional services not currently being offered here so we can even better serve our communities.

Early Volunteer & Woodstock

by Julian Rappaport

One small piece of history that ties Frances Nelson to the times in which it began: An early volunteer nurse was Lois (Yasgur) Herring, who was employed at Carle. Lois came to Champaign-Urbana with her husband, an African American graduate student. Her family farm in upstate New York was the Yasgur farm that hosted the Woodstock Music Festival. She tragically died in an automobile accident in Champaign in 1977.

Service of the Heart

Alina Paul, MD

Written August 29, 2019 as a letter to the editor to the News Gazette.

The other day I was thinking about the roots of Frances Nelson clinic aka Promise Health Care where I have worked since 2016. The founder Miss Frances Nelson was an African-American woman in the 1940’s who opened her home to African American children who had nowhere to live.

Today nearly 80 years later her efforts have multiplied and expanded to include medical, dental, mental and prenatal services with affordable care to the underserved of Champaign-Urbana Communtiy.

Miss Nelson is an inspiration to us to remind us daily to focus on not what we cannot do but what we can to help alleviate at least part of the suffering of our fellow man.

As on fo the staff members in the clinic I am so honored to be part of her mission – to be part of the solution to the growing needs of our communities where we live.

Let us start by consciously giving our hearts fully into treating every human being as valuable.

I thank God for your faithful service Miss Nelson. May we as individuals in whatever capacity we serve help to keep your legacy alive with spirit of love and genuineness.

Tribute to Frances Friedman

by Catherine Friedman

Perhaps I’m biased, but I believe that Frances Friedman, my mother, was fundamental to the growth and expansion of the Frances Nelson Health Center during its early years.  I think everyone who knew her would agree that as the Center’s Executive Director, my mother was a dynamic and welcoming leader who strengthened and extended the Center’s services.  She wrote grants, pressured politicians, twisted bureaucrat’s arms, built community coalitions, and spoke out to anyone who would listen to round up the funding needed to support the Center’s mission.  She was a leader who truly cared about the community the Frances Nelson served.

Well Wishes on Your 50th From Christie Clinic

Dr. William Pierce, Chief Medical Officer, Christie Clinic

“Christie Clinic congratulates Frances Nelson Health Center/Promise Healthcare as it celebrates its 50th Anniversary! I have been in Champaign-Urbana healthcare and at Christie Clinic for 30+ years. Frances Nelson Health Center/Promise Healthcare has been the rock solid entity that has helped bridge the gap in healthcare in our community. Over the years, Christie Clinic physicians have extended professional services to its patients and financially supported its growth initiatives to improve the health of the community through treatment, prevention and education.  Touring their facilities you will note the Esprit de corps of the staff is remarkable as they compassionately and professionally care for their patients. We wish them continued success!”

What a Journey: A Community coming together to increase access to health care services, 2004-2006

By:  Tammy Lemke, Former President/CEO United Way of Champaign County, 2002-2007

I remember like it was yesterday reviewing the Champaign County Community Needs Assessment and thinking that there must be a solution to meeting our community’s most pressing need, Access to Health Care.  I remember drafting a white paper for the United Way Board outlining the needs and how, we, as the United Way, could make a difference in this area.   I remember the Board saying, “We agree – now what is our next step?”

Of course, the next step was to meet with our community’s health care providers on how to move the needle in providing access to health care, specifically primary care.  We started with a conversation with Andrea Goldberg of Frances Nelson Health Center to see how we could help in supporting their mission.   Her answer seemed so easy – increase the capacity of FNHC to provide services by relocating and expanding the clinic. 

The next step was to reach out to those in the field, Carle Clinic, Christie Clinic, Carle Foundation Hospital and Provena Covenant Medical Center.  All agreed on the need and on a possible solution.  In fact, under the leadership of Cathy Emanuel at Carle Hospital, a strategic thought process was in development that included assisting FNHC in expanding.

Everyone had a similar solution.  Relocate and expand FNHC.  Easy right?  As we know, mobilizing the money to expand and relocate a primary care clinic is not easy.   United Way agreed to take a key role in the project. After months of working through strategies and mobilizing resources with the leadership at Frances Nelson, Carle, Christie and the Community, the current space on Bloomington Road was identified.   Carle Foundation Hospital provided the leadership in securing the facility and Walt Manske was appointed as the construction manager.  Walt was the driving force in ensuring the clinic met the needs of our community now and in the future. 

During the construction phase, the project leadership continued to mobilize resources to furnish the facility and to ensure operational dollars were available to meet the increased staffing costs of an expanded clinic.  There were many early morning meetings at Panera between Andrea Goldberg and me on whether or not this vison would be a realty!  Andrea was key to ensuring the clinic was operationally ready to go and the glue that held her staff together.

The new clinic was dedicated in November 2006 with all key stakeholders and leaders in attendance. 

When community stakeholders come together, great things can happen.   I am so proud to see this wonderful community asset flourishing under the leadership of Promise Healthcare.


Promise Healthcare is dedicated to improving the health of the community through treatment, prevention, and education.  We seek to be the premier healthcare provider for all regardless of ability to pay by exceeding patient expectations and improving the health of our community.

We deliver primary medical, behavioral health, and dental services to the underserved.  Promise Healthcare provides over 44,000 patient visits and cares for over 12,000 patients annually through Frances Nelson, our SmileHealthy dental programs, satellites on Walnut at Rosecrance, the OSF Healthcare Heart of Mary Community Resource Center, the Urbana School Based Health Center and our mobile clinics. www.promisehealth.org