Western Plains Public Health Notice of Privacy Practice
Western Plains Public Health Statement of
Acknowledgement, Authorization & Assignment of Benefits:
I hereby consent to care by Western Plains Public Health (WPPH)
I hereby authorize WPPH to release and/or exchange information with a third-party payer. I understand this information will be held confidential and used only to exchange written or verbal information as related to payment for my care, treatment, and evaluation.
If I am the Client or an individual legally obligated to pay for medical services provided to the Client or a Guarantor of payment, I agree to pay and I am financially responsible for WPPH's established charges provided to the Client not covered by a third-party payer. I assign and authorize any third-party payer/insurer to make direct payment to WPPH of all benefits payable for the Client's care.
I hereby consent and state my preference to have WPPH, and its staff, communicate with me by email, automated calling system or standard SMS messaging regarding my services. I understand that email, automated calling systems and standard SMS messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email, automated calls and standard SMS messaging regarding my information might be intercepted and read by a third party. I understand this authorization is voluntary, and WPPH may not condition services on whether I sign this authorization. This authorization may be revoked by written notice to WPPH.
A copy of the appropriate Centers for Disease Control and Prevention Vaccine Information Statement(s) and/or Emergency Use Authorization Face Sheet has been provided. I have read the information about the disease(s) and the vaccine(s). I understand the benefits and risks of the vaccine(s) cited and ask that the vaccine(s) be given to me or to the person named (for whom I am authorized to make this request). Vaccine Information Statements:
https://www.cdc.gov/iis/code-sets/vis-url-table.html
Information collected will be used to document authorization of receipt of vaccine(s). Information may be shared through the North Dakota Immunization Information System (NDIIS) with other entities in accordance with North Dakota Century Code 23-01-05.3.
https://www.legis.nd.gov/cencode/t23c01.pdf#nameddest=23-01-05p3