To make an appointment, please complete the “Adult Intake Form” below and someone will reach out to you to make an appointment. You can also call us at 215-333-2600 and leave a message. If you prefer email, you can reach out to email@example.com with your name, contact information, and your reason for visiting us.
Eligibility Requirements (you must):
- To be an eligible patient, you must either have no health insurance OR have a household income within 250% of the federal poverty level (low-income).
|Household Income Must Be Less Than:
PRIVACY AND HIPAA
Summary HIPAA Notice of Privacy Practices
The SHAMS Clinic complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The SHAMS Clinic protects confidential health care information, known as “Protected Health Information” (PHI).
Below is a summary of your privacy rights under HIPAA.
The SHAMS Clinic legal duties and privacy practices regarding your PHI are also included in this Summary Notice.
Summary of Your Privacy Rights
The SHAMS Clinic may use and give your health information to:
- Treat you
- Operate health care services
The SHAMS Clinic may use and give your health information for:
- Law enforcement requests
- Judicial and administrative proceedings related to legal actions
- Healthcare fraud and abuse detection or compliance with the law
- Use by another healthcare provider treating you
- Government health oversight activities
- Reports required by law related to births, deaths or diseases
- Reports required by law related to neglect and abuse, or domestic violence
- Notifying a party about exposure to a possible communicable disease
- Military, national defense and security or other governmental functions
- Workers’ compensation purposes and in compliance with related laws
- Averting a serious threat to public health and safety
- You have the right to:
- Inspect or get a copy of your medical record
- Change information on your medical record if you think it is incorrect
- Get a list of persons whom The SHAMS Clinic shared your PHI
- Ask The SHAMS Clinic to limit the information it shares
- Ask for a copy of your privacy notice
- Write a letter of complaint to The SHAMS Clinic or the federal government
If you have any questions or if you wish to file a complaint, or exercise any rights listed in this Summary, please contact The SHAMS Clinic at firstname.lastname@example.org