PATIENT ADMISSION AND REGISTRATION INFORMATION WELCOME We look forward to providing you the best possible health care experience in our ambulatory surgery facility. Modern medical techniques and equipment have made it possible for you to have non-emergent outpatient surgery and return to the comfort of your home the same day. A group of highly-respected and well-trained physicians from the surrounding community and Neospine, LLC have come together to offer you a safe, high quality surgical care facility, and was designed to offer you an affordable convenient alternative to overnight hospitalization, enhancing your choices for high quality ambulatory health care and surgical services. SURGICAL SERVICES INCLUDE: Pain Management Procedures Spine Procedures General Surgery DRIVING DIRECTIONS We are located in the Community Physicians Pavilion building, Suite 130 (300 Exempla Drive) south of the Good Samaritan hospital in Lafayette. Take Hwy 287 to Campus Drive, go East on Campus Drive, turn left at the 2nd entrance. You can park in lot 4A; come into the south entrance of the building, our entrance is the first door on your left. PROVIDING QUALITY CARE All of us at Minimally Invasive Spine Institute are committed to providing you with the best possible care. This commitment is demonstrated by our licensure by the Colorado Department of Health Services and Medicare certifications from the Centers for Medicare and Medicaid Services (CMS). These organizations have established high standards for the practice and delivery of surgical services. As a result, we strive to deliver the highest level of care to you, our patients, and therefore uphold licensing and certification.
PROCEDURE SCHEDULING Your physician s office staff will assist you with coordination of scheduling the date and time of your procedure. To make your visit with us a convenient and comfortable experience, please provide accurate and complete information regarding your name, address, birth date, social security number, and current health insurance information. Although you may have previously submitted this information, spelling errors and outdated information could lead to unexpected and possible lengthy delays with the admitting process. Please note: Inaccurate patient information could lead to our inability to accurately bill your insurance company. Bad claims information may cause the insurance company to deny your benefits. In this event, all charges for the procedure would become your responsibility. Please take a few minutes to make sure your personal and insurance information is accurate and up-to-date. ADMISSIONS PAPERWORK To expedite your admitting experience, we are providing you with many, (but not all) of the forms that require your review and signature prior to your procedure. By taking a few moments at home to review, read, and sign the enclosed forms, the overall admitting process will be more pleasant. We are required to have you complete certain forms at the facility on the day of admission. These will be provided to you when you arrive at the center. Please take a few minutes to review and complete the following documents necessary for admission to Minimally Invasive Spine Institute. This packet should contain the following documents: Patient Information Patient Billing Procedures General Information about Anesthesia Patient Rights and Responsibilities If any of these documents are missing or you have any questions about them, please call the surgery center at (303) 539-2533 and we will make arrangements to send you additional copies and answer your questions. Please make sure to bring all completed paperwork with you on the date of your procedure. We hope this registration packet assists you with a convenient and comfortable admission process. We look forward to seeing you soon and providing you with a positive health care experience. PREPARING FOR YOUR PROCEDURE The night before your surgery you may eat a light snack before 10pm. Do not drink or eat anything after midnight, including water or coffee, unless instructed otherwise by the surgery center staff. Adhering to this guideline will reduce the possibility of nausea and vomiting following anesthesia. You should brush your teeth, remembering not to swallow anything. Refrain from using mints, chewing gum or cigarettes. Failure to follow these instructions may result in the cancellation of your surgery. Please do not take any medication after midnight unless instructed by your physician or our office. If you are diabetic or on blood pressure or heart medication, obtain specific instructions from the surgery center. If you have not been contacted at least 24 hours before your surgery, please call the surgery center (303) 539-2533, and ask to speak with a nurse to receive specific instructions.
FOLLOW THESE GUIDELINES BEFORE YOUR SURGERY Please arrange in advance for a responsible adult to drive you home and remain with you the first 24 hours after surgery. You will not be allowed to have your procedure without prearranging this responsibility. You cannot drive yourself or be left alone. If you have received your post-procedural medications from your physician, we recommend that you fill these medications before your procedure. This will prevent you from having to stop and obtain them on the way home following your procedure. Please notify your surgeon before coming to the center if there is any change in your physical condition, such as a cold or fever. Be prepared to sign a form giving your consent for the procedure. If you are under 18 years of age, a parent or legal guardian must accompany you to sign the consent form. Please consider traffic and parking delays. Plan to arrive promptly at your designated time. Free parking is available in lot 4A on the south side of the building. This is where you should park when you arrive. A nurse will provide you with a patient gown and a place to store your clothing in the preoperative area. We will also check your temperature, blood pressure, and pulse. You will also be asked to empty your bladder before your procedure. Your family, friends and companions will be asked to wait in the front lobby during your procedure or surgery. They cannot observe your procedure. The surgeon will speak with your family immediately following surgery. If you wear contact lenses, dentures, or bridgework, please leave them at home, if possible. If you wear glasses, bring your case for their safekeeping. For your other personal possessions, you will be asked to have a responsible adult hold them for you during the procedure. THE DAY OF SURGERY To help us meet all your health needs, please follow these guidelines: Please bath or shower before your surgery. Remove all makeup. Do not use lotions or oils after bathing. Wear loose, comfortable clothing, such as sweat suits and easy-to-button shirts or blouses that fit extra large to accommodate a large bandage after your procedure. Wear comfortable flat-soled shoes. Leave all unnecessary valuables, such as jewelry and contact lenses at home. Please note: we do not have a safe or the ability to securely store your personal valuables; therefore, we cannot be responsible for damaged or lost property. Following is a check list of required items for admission: Photo I.D. or driver s license. Insurance Information (card) or worker s compensation information/authorization. Cash, check, or credit card to pay for your co-payment or deductible requirements. Advance Healthcare Directive (if available) Completed paperwork from this packet POSTSURGICAL CARE SUGGESTIONS Before you leave the center, you will be given verbal and written instructions for your care at home. After you have returned home, please follow your doctor s orders regarding diet, rest, medication and activity. If you are tolerating clear liquids, then try soft/bland foods, and then progress your diet as tolerated. By the next day you should be back to your normal diet. You may feel a little sleepy, lightheaded or dizzy for several hours after your operation. Do not sign any important papers or make any significant decisions for at least 24 hours. Do not drive a car, smoke, drink alcoholic beverages, operate machinery or cook for at least 24 hours after returning home from your procedure.
If you have any questions or concerns after your procedure, please contact your doctor immediately. A nurse form the center will call you within a few days after your surgery to see how you are recuperating and answer any additional questions you might have. OUR CARE OF YOUR CHILD (16 and older) At the Minimally Invasive Spine Institute, we strive to meet the special needs of children by creating a comfortable, relaxing atmosphere. Parents should discuss the procedure with the child beforehand to help alleviate anxiety. A tour of the facility can be arranged to provide additional information and enhanced comfort. Parents can call the center to schedule a tour. Parents may remain with the child up until the time of surgery. At least one parent must remain at the surgery center from the time of the child s admission through discharge. After surgery, parents may rejoin the child in the recovery room. If possible, we recommend that one adult drive home while another cares for the child. Unless absolutely necessary, we recommend that you do not bring the child s siblings to the center. WE ARE HERE TO HELP If you have any questions or concerns, please contact the center at any time. We are dedicated to making your visit with us comfortable as possible. A copy of the Patient Rights and Responsibilities is enclosed in this admissions packet. All of us at Minimally Invasive Spine Institute appreciate the trust you have placed in our facility for your health care needs. We work hard every day to provide you and your family with a high quality, safe, and efficient experience. At any time during your visit, please feel free to comment to the staff regarding recommendations and clarifications for your visit. We will gladly do what we can to accommodate your special needs. Thank you for choosing Minimally Invasive Surgery Center for you health care needs. 300 Exempla Cir Suite 130 * Lafayette, CO 80026 303-539-2533 * Fax 303-539-2534 Or visit us on our website at www.spinemisi.com
Patient Information/Assignmentof Benefits/Release of Info/HIPAA/Rights and Responsibility Acknowledgement Name Sex M F Birthdate Address Phone # E-mail Emergency Contact/Phone # Assignment and Release I certify that I, and / or my dependent(s), have insurance coverage with and assign directly to Minimally Invasive Spine Institute all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above named healthcare provider/institution may use my health care information and may disclose such information to the above-named insurance company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end my current treatment plan if completed one year from the date signed below. Signature Date Please Print name of Patient, Parent, Guardian or Personal Representative Relationship to Patient Release of Healthcare Information: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person s involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for your care of your location, general condition or death. To whom may we disclose your protected healthcare information to: Name Relationship Phone Number Name Relationship Phone Number Name Relationship Phone Number Name Relationship Phone Number By signing below, I hereby acknowledge that I have reviewed and/or received a copy of Minimally Invasive Spine Institute Notice of Privacy Practices and Patient Rights and Responsibilities, as of the date set forth below. Patient or Responsible Party Signature Date Witness Date
Patient Billing Procedures Thank you for choosing Minimally Invasive Spine Institute as the place to have your procedure performed. The Minimally Invasive Spine Institute specializes in performing minimally invasive spine and neurosurgery with the newest, state-of-the-art equipment available. The clinical staff is dedicated to this type of surgery so that each patient will receive the highest quality care possible. Our goal is to ensure that your encounter is pleasant, efficient and above all, as safe as possible. As a courtesy to our patients, we will gladly process your insurance for you, understanding that the agreement you have with your insurance company is between you and them. Since billing procedures can be confusing, we want to ensure that you understand what is being billed and the amount, if any, that you may owe. The business office will be contacting you prior to your date of service to give you an ESTIMATED patient responsibility that will be due at time of service unless other arrangements are made. Our billing department will forward a final bill to you for any co-payments, deductibles or payments due once appropriate adjustments and payments have been made. For your information, the bill you receive from Minimally Invasive Spine Institute is for the FACILITY ONLY. Failure to make payment may result in collection activity. Any fees associated with collection activities will become your responsibility. Following your surgery, the physician performing your procedure, an anesthesiologist and a neuromonitor, if they participated in your treatment, will bill your insurance company for his/her services. Also, if you received implants or other medical devices and/or equipment, your insurance may be billed by an outside vendor as well. Finally, your insurance company will receive a bill from Minimally Invasive Spine Institute for your procedure; i.e., the use of the facility and nursing staff. After billing your primary insurance carrier, any secondary insurance will be billed. You will then be responsible for the payment of some amounts not paid by your primary or secondary insurance carriers. EXCEPT FOR SPECIFIC ARRANGEMENTS, for patients with no insurance, the facility will offer a 40% discount from charges (excluding the cost of implants or equipment) for cash at the time of admission. The facility may not currently participate with all insurance companies. In circumstances in which the facility is in negotiations with the patient s insurer, the facility will adjust from the bill any difference between the out-ofnetwork and in-network obligations, provided that the patient s insurer does not object. In the event that your insurance carrier issues a check directly to you, it is the responsibility of the insured to endorse the back of the check OR send the amount equal to the check to Minimally Invasive Spine Institute along with a copy of the explanation of benefits. Failure to forward this payment may result in collection activity against you. Please feel free to contact the facility at 303-539-2533, if you have any questions regarding the above information or visit our website at www.spinemisi.com. Thank you for the trust you have put in us. Patient Signature Witness Date Date
GENERAL INFORMATION ABOUT ANESTHESIA: Modern anesthesia techniques are generally safe and well-tolerated by most patients. An anesthesiologist will talk to you prior to surgery and discuss your individual method for anesthesia. It is important that you familiarize yourself with the anesthesia techniques and issues written below so that you may discuss them more fully with your anesthesiologist. This form has been developed to assist you in making an informed healthcare decision, but it should not be your only source of information in making decision. Minor issues experienced from anesthesia may include nausea and vomiting, headache, or injury to teeth or dental work. The major techniques and their related issues are outlined below. Although rare, unexpected severe complications can occur and include the remote possibilities of: infection, bleeding, medication reactions, blood clots, loss of sensation, loss of limb function, paralysis, stroke, brain damage, heart attack, or possibly death. It is important for you to understand that these risks apply to all forms of anesthesia and that additional or specific risks are identified below. The anesthetic technique to be used during your procedure is determined by many factors including your physical condition, the type of procedure you are having, your doctor s preference, as well as your own desire(s). In some cases, an anesthesia technique that involves the use of local anesthetics, with or without sedation, may not succeed completely. All forms of anesthesia involve some risks and no guarantees or promises can be made concerning results of your procedure or treatment. TYPES OF ANESTHESIA: GENERAL ANESTHESIA (Requires Anesthesiologist or Anesthetist) MONTIORED ANESTHESIA CARE with Sedation (Requires Anesthesiologist or Anesthetist) Expected Result Technique Risks (including but not limited to) Expected Result Technique Risks (including but not limited to) Total unconscious state, vital signs monitored and maintained, no patient recall. Drug injected into bloodstream, breathed into lungs, or by other routes. Possible placement of tube into the windpipe. Mouth or throat pain, hoarseness, injury to mouth or teeth, awareness under anesthesia, injury to blood vessels, aspiration or pneumonia. Reduced anxiety and pain, partial or no patient recall. Drug injected into bloodstream, breathed into lungs, or by other routes producing a semi-conscious state. An unconscious state, depressed breathing, injury to blood vessels, some degree of awareness. Additional information on other side.
ANESTHESIA TYPES CONTINUED: SPINAL OR EPIDURAL ANALGESIA/ ANESTHESIA o With Sedation o Without Sedation (Requires Anesthesiologist or Anesthetist) INTRAVENOUS REGIONAL ANESTHESIA o With Sedation o Without Sedation (Requires Anesthesiologist or Anesthetist) CONSCIOUS SEDATION WITHOUT ANESTHESIA PROVIDER Expected Result Technique Risks (including but not limited to) Expected Result Technique Risks (including but not limited to) Expected Result Technique Risks (including but not limited to) Temporary decreased or loss of feeling and/or movement to lower part of body, decreased low back pain and/or leg pain. Drug injected through a needed placed immediately outside the spinal canal. Temporary headache, backache, buzzing in the ears, convulsions, infections, persistent weakness, numbness, residual pain, injury to blood vessels, decreased blood pressure. Temporary loss of feeling and/or movement of a limb. Drug injected into veins of arm or leg while using a tourniquet. Infection, convulsions, persistent numbness, residual pain, injury to blood vessels, some degree of awareness. Reduced anxiety and discomfort, allows patient to tolerate uncomfortable procedures while maintaining the ability to respond to verbal and tactile stimulation. Drug injected into bloodstream producing a reduced anxiety and discomfort level. An unconscious state, depressed breathing, injury to blood vessels, degree of awareness. As a patient you have the right to have all of your questions answered prior to induction of anesthesia. Please consult with the staff or physician at any time regarding any issue.
Minimally Invasive Spine Institute Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY This notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or healthcare operations and for other purposes that are permitted and 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 and related healthcare services. We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, you can receive any revised Notice of Privacy Practices by contacting the facility where you were seen. Just request that a revised copy be sent to you in the mail or ask for one at your next appointment. 1. How We May Use and Disclose your Protected Health Information Your healthcare provider will use disclose your protected health information as described in Section 1. Your protected health information may be used and disclosed by your healthcare provider, our office staff and others outside of our facility that are involved in your care and treatment for the purpose of providing healthcare services to you. Your protected heath information may also be used and disclosed to pay your healthcare bills and to support the operation of NeoSpine. Following are examples of the types of uses and disclosures or your protected healthcare information that Neospine is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our facility. Treatment: We may use protected health information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students or other personnel who are involved in your care. Different departments of our facility also may share protected health information about you in order to coordinate your needs, such as prescriptions, lab work and x-rays. We also may disclose protected health information about you to individuals outside NeoSpine who may be involved in your medical care, such as family members or others we use to provide services that are a part of your care. When required, we will obtain your authorization before disclosing any of your information. Only the minimal amount of information will be revealed during any disclosures. Payment: Your protected health information will be used, as needed, to obtain payment of your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity and under taking utilization review activities. For example, 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 hospital admission. Healthcare Operations: We may use or disclose as-needed, your protected health information in order to support the business activities of your healthcare provider and NeoSpine. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities and conducting or arranging for other business activities. For example: your health information may be disclosed to members of the medical staff, risk or quality improvement personnel and others to: Evaluate the performance of our staff Assess the quality of care and outcomes in your case and similar cases Learn how to improve our facilities and services Determine how to improve continually the quality and effectiveness of the health care we provide In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician or therapist. We may also call you by name in the waiting room when your healthcare provider is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We will share your protected health information with third party business associates that may perform various activities (e.g. billing, transcription services) for NeoSpine. Whenever an arrangement between our facility and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information, as necessary, to provide you with information about treatment alternatives or other health related benefits and services that may be of interest to you. Other Permitted and Required Uses and Disclosures that May Be Made With your Authorization, or Opportunity to Object You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your healthcare provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case only the protected health information that is relevant to your healthcare will be disclosed. We may use and disclose your protected health information in the following instances: Facility Directories: Unless you object, we may disclose in our facility your name, the location at which you are receiving care, your condition (in general terms) and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people who ask for you by name. Members of the clergy will be told of your religious affiliation. Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person s involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare. Other permitted and required uses and Disclosures That May be made Without Your Authorization or Opportunity to Object. disclose your protected health information without your authorization in the following situations: We may use or
Required by Law: We may use or disclose your protected health information to the extent, that the, use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures. Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. Communicable Disease: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information to the governmental entity or agency authorized to receive such information if we believe that you have been a victim of abuse, neglect or domestic violence. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws. Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to: report adverse events, product defects or problems, biologic product deviations, tract products, to enable product recalls, to make repairs or replacements or to conduct post marketing surveillance, as required. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to a order of a court or administrative tribunal; to the extent such disclosure is expressly authorized) in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement: We may discuss protected health information so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and those otherwise required by law (2) limited information requests for identification and location purposes (3) pertaining to victims of a crime (4) suspicion that death has occurred as a result of criminal conduct (5) in the event that a crime occurs on the premises of NeoSpine and (6) medical emergency (not on NeoSpine s premises) and it is likely that a crime has occurred. Coroners, Funeral Directors and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaver organ, eye or tissue donation purposes. Research: We may disclose your protected health information to researchers with their research had been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your local health information. Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits or (3) to foreign military authority if you are a member of that foreign military service. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the president or others legally authorized. Workers Compensation: Your protected health information may be disclosed by us as authorized to comply with workers compensation laws and other similar legally established programs. Required Uses and Disclosures: Under the law, we must make disclosures to you, and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et.seq., Privacy of Individually identifiable Health Information. 2. Your Rights Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A designated record Set contains medical and billing records and any other records that your healthcare provider and NeoSpine use for making decisions about you. Under federal law, however, you may not inspect or copy the following record; records; psychology notes; information compiled in reasonable anticipation of; or use in, a civil criminal or administrative action of proceeding and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. Please contact our Medical Records Department if you have questions about access to your medical record. If you request a copy of the information, we may charge a fee for the costs of retrieving, copying, mailing and any other supplies associated with your request. You have the right to request a restriction of your protected health information. This means that you may ask us not to use or disclose your protected health information