Patient Enrollment Form

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FILL THIS SECTION OUT ONLY IF YOU HAVE A REGISTERED NMMCPA CAREGIVER:

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AUTHORIZATION TO RELEASE INFORMATION: I agree and authorize Organtica to contact producers and the New Mexico Department of Health to share any information regarding my license to use and possess medical cannabis. This authorization allows entities to share information, verbal and written, in compliance with the Lynn and Erin Compassionate Use Act. I understand that I may revoke this authorization in writing and that revocation of this Authorization will negate my ability to purchase medical cannabis from the producers indicated above. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY (HIPAA): The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes. We believe that all medical and other health information is private and should be protected. The Privacy Rule, a Federal law, gives you rights over your health information and sets rules and limits on who can look at and receive your health information. The Privacy Rule applies to all forms of individuals' protected health information, whether electronic, written, or oral. The Security Rule, a Federal law that protects health information in electronic form, requires entities covered by HIPAA to ensure that electronic protected health information is secure. HOW IS THIS INFORMATION PROTECTED: • Covered entities must put in place safeguards to protect your health information. • Covered entities must reasonably limit uses and disclosures to the minimum necessary to accomplish their intended purpose. • Covered entities must have contracts in place with their contractors and others ensuring that they use and disclose your health information properly and safeguard it appropriately. • Covered entities must have procedures in place to limit who can view and access your health information as well as implement training programs for employees about how to protect your health information. WHO CAN LOOK AT AND RECEIVE YOUR HEALTH INFORMATION: The Privacy Rule sets rules and limits on who can look at and receive your health information. To make sure that your health information is protected in a way that does not interfere with your health care, your information can be used and shared: • For your treatment and care coordination • With your family, relatives, friends, or others you identify who are involved with your health care, unless you object • To make sure doctors give good care • To protect the public's health, such as by reporting when the flu is in your area your health information cannot be used or shared without your written permission unless this law allows it. For example, without your authorization, your provider generally cannot: • Give your information to your employer • Use or share your information for marketing or advertising purposes • Share private notes about your health care Hub producers follow all HIPAA guidelines in order to provide you with a safe, secure, private, and professional service. WHAT INFORMATION IS PROTECTED: • Information your doctors, nurses, and other health care providers put in your medical record. • Conversations your doctor has about your care or treatment with nurses and others. • Billing information about you. • Most other health information about you held by those who must follow these laws. POLICIES: 1. Your client information will be kept confidential unless to comply with State law. This specifically includes the sharing of information with other licensed producers and NMDOH. Client files may be stored in open file racks and will not contain any coding which identifies a client’s condition or information,which is not already a matter of public record. 2. We will send you regular email communications informing you of changes to Organtica policy as well as new products and services. 3. Organtica utilizes a number of vendors in the normal conduct of business. These vendors may have access to PHI and they all agree to abide by HIPAA rules and regulations. 4. Your confidential information will not be used for the purposes of marketing or advertising of non-supported third party products, goods or services. 5.You will have access to your client records in accordance with state regulations - within a reasonable timeframe. 6. We reserve the right to refuse service to anyone for conduct deemed aggressive or abusive by Organtica. 7. We reserve the right to modify these policies to serve the needs of Organtica and its clients.

 

REQUIREMENTS

1. Valid NM DOH Medical Cannabis Program Membership 2. Clear photocopy of Patient ID Card and current photo ID 3. Completed and signed enrollment package

PROCESS

Complete this application, include photocoy/scans of your NMMCP card and valid driver’s license and Submit Via this page. Please bare in mind that we can expedite applications with all information provided on this form. Thank you.
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