Memphisvascular.com



1019175-952507695 Poplar PikeGermantown, TN 38138901/683-1890FAX: 901/334-5760007695 Poplar PikeGermantown, TN 38138901/683-1890FAX: 901/334-5760-204470-24765000Chart No.: ______________ Notice of Privacy PracticesI, __________________________________ , (please print your full legal name) have been shown the (Privacy Policy for this office), and have been offered a copy of such policy to keep for my records.I hereby give permission for this office to leave messages on the answering service, voicemail/email at____My home (please initial) ___________My Cell (please initial) ___________My office (please initial) ___________Email/Text(please initial) _______I hereby give the following people permission to receive information from this office on my behalf:___________________________________________________________________Name of PersonRelationship to me (e.g., Parent, friend, spouse)___________________________________________________________________Name of PersonRelationship to me___________________________________________________________________Name of PersonRelationship to me_____________________________________________ ____________________________________(Signature)(Date)NOTICE TO PATIENTSMemphis Vascular Center has a fee of $25.00 per request for completion of papers that include, but will not be limited to FMLA, Disability, and Third Party Insurance Companies making payment to patients. This fee may be paid either by cash, check or credit. Please make checks payable to MRPC or you may call our billing office at (901)291-2400. These papers will be available for pick up at our office: 7695 Poplar Pike, Germantown, TN 38138.Please allow 5-7 business days for completion of this paperwork before pick up.Memphis Vascular Center7695 Poplar PikeGermantown, TN 38138901-683-1890Notice of Privacy Practices:We are required by law to protect the privacy of your medical information. Please review this carefully.YOUR HEALTH INFORMATION RIGHTSYour medical record belongs to you as the patient. You have the right to inspect and obtain a copy of this information at any time. You can request communication between physicians regarding your medical records at any time. You may also revoke the authorization to disclose health information except to the extent it has already been disclosed.OUR RESPONSIBILITIESMemphis Vascular Center is required to maintain privacy of your health information; to provide you with notice of our legal duties and privacy practices with respect to information we collect and maintain about you. We abide by the terms of this notice, and notify you if we are unable to agree to a requested restriction. We reserve the right to change our practices and to make new provisions for all health information we maintain. We will not use or disclose your health information without your authorization, except as described in this Notice.EXAMPLES OF DISCLOSURES FOR TREATMENTMemphis Vascular Center will use your medical information for treatment purposes. An example is the information obtained by a nurse or a physician that will be recorded in your medical record. This information will be used by members of the healthcare team to determine treatment and response to medical intervention.OTHER PERMITTED DISCLOSURES AND USES OF YOURHEALTH INFORMATIONUnless you notify us that you object, we may use or disclose health information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition. Unless you notify us that you object, we may disclose your health information to members of the clergy. We, as health professionals, may disclose to a family member, other relative, or any other person you identify, health information relevant to that person’s involvement in your care. We may disclose your protected health information to a group health plan, health insurance issuer, or HMO with respect to a group health plan, who may disclose your protected health information to the plan sponsor. We may also contact you to provide additional information. (i.e.: to verify your policy number and insurance verification).Concerning messages left: Memphis Vascular Center may leave a message at the following numbers: Please see attached page to be left for your medical record.We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.As required by law, we may disclose your health information to pubic health or legal authorities charged with preventing or controlling disease, injury, or disability.We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority, or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.We will disclose appropriate medical billing information to a collection agency should efforts to collect from your insurance company or yourself become unproductive. We file insurance as a courtesy for patients, but the responsibility for payment is with the patient or the responsible party--as they are the policyholder.RIGHT TO OBTAIN NOTICEYou have the right to obtain a paper copy of this Notice from us, upon request, even if you have agreed to accept this Notice electronically. This Notice may be changed at any time.REQUESTING COPIES OF YOUR MEDICAL RECORDYou may request a copy of your medical record. We will provide a copy within 10 working days after you submit your request. We will charge $.25 for each page copied.REQUESTING RESTRICTIONS ON USE AND DISCLOSUREYou may request in writing that we not use or disclose your information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. You also may request that your health information not be disclosed to family members or friends who may be involved in your care. You must state the specific restriction requested and to whom you want the restriction to apply. This office is not required by law to agree to a restriction that you may request.REQUESTING AND ACCOUNTINGYou also have the right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, payment or related administrative purposes. It excludes disclosures we may have made to you, or to family members involved in your care. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter time frame.The right to receive this information is subject to certain exceptions, restrictions and limitations.REQUESTING CHANGES TO YOUR HEALTH RECORDIf you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information.FOR MORE INFORMATIONIf you have questions or would like additional information, please contact us at (901) 683-1890. If you believe your privacy rights have been violated, you can file a complaint with the Secretary of the Federal Health and Human Services Department. There will be no retaliation for filing a complaint.-204470-24765000MEMPHIS VASCULAR CENTERPATIENT REGISTRATIONPatient InformationLast Name ________________________________First__________________________ MI _____________Address ________________________________City/State/Zip ______________________________________Phone-Home ( )___________________________Cell Phone ( )___________________________________Date of Birth ________________________________SS No.__________________________________________MVC M.D. ________________________________Sex: M F Martial Status: S M D W SepReferred By:Physician [ ]Friend/Relative [ ]Emergency Room [ ]Yellow Pages [ ] Other ______________Referring MD/PCP _______________________________Physician Phone ___________________________________Physician Address _______________________________City/State/Zip ___________________________________Employer _______________________________Employer Phone ___________________________________Employer Address _______________________________ City/State/Zip ___________________________________Emergency Contact _______________________________Contact Phone ___________________________________Contact Address _______________________________City/State/Zip ___________________________________Responsible PartyLast Name _______________________________First___________________________ MI _____________Address _______________________________City/State/Zip ______________________________________Phone-Home ( ) __________________________DOB _________________ SS No. ____________________Employer _______________________________Employer Phone ____________________________________Employer _______________________________City/State/Zip ______________________________________Insurance InformationPrimary Insurance _______________________________Policy No. _________________ Group No. _____________Policy Holder _______________________________Ins. Phone _______________________ DOB ____________Policy Holder Address _______________________________SS No. ________________ Referral No. ________________Other Insurance Co. _______________________________Policy No. _______________ Group No. _____________Policy Holder _______________________________SS No.____________________ DOB _________________Policy Holder Address ________________________________City/State/Zip ______________________________________I hereby authorize (a) payment of insurance benefits otherwise due to me to be made directly to the treating physician, (b) release of information including protected health information to insurance companies as needed to file for payment for services incurred, (c) Memphis Vascular Center to obtain and submit records as may be necessary in the diagnosis or treatment, and (d) understand that I am financially responsible for payment to Memphis Vascular Center for charges related to service provided to or incurred by me or my dependents.Signature (Responsible Party) __________________________________________________________ Date ___________________Signature (Witness __________________________________________________________ Date __________________ PATIENT MEDIC AL HISTORYPast Medical History-please check any of the boxes that apply:AnemiaGlaucomaClotting DisorderHepatitis: type: A / B / C / UnknownArthritis HIVAscites/ Abdomen DistentionHigh CholestoralAsthmaHigh Blood Pressure CAD (coronary artery disease) Heart Attack Cancer: type: ________________ IBS: Crohn’s / Ulcerative Colitis / other: Cerebral Aneurysm Kidney (Renal) DiseaseCirrhosis OsteoarthritisCongestive Heart Failure (CHF) Osteoporosis CVA (Stroke) Pacemaker Defibrillator PVD (peripheral vascular disease) Depression Seizure Disorder Diabetes: type: I / II Tuberculosis Emphysema Thyroid Problems Encephalopathy/ Confusion Stroke-like symptoms (TIA) Endometriosis Uterine Fibroids GERD (reflux disease Other: ____________________________Surgical History-please check any of the boxes that apply and list dates if they are known:Appendix RemovedIUDBladder SuspensionKidney Removal: Left / Right / BothHeart Bypass: # of bypasses: ______Knee replacement: Left/Right/ BothCarotid Endarterectomy: Left / RightLEEPCarpel Tunnel Syndrome: Left / Right/ BothLiver ResectionCataract Right / LeftMastectomy: Left / Right / BothCesarean Section Organ Transplant: What organ: ______________ Gall bladder removed Orthopedic Surgery: ___________________________Colon Resection Stents: Please list:__________________________ Exploratory Lap Thyroidectomy: Total / Partial Femoral Bypass TIPS Hernia Repair Tonsillectomy Hysterectomy: Total / Partial Abdominal / Vaginal/ Oophorectomy Tubial Ligation: ____________________ Other: ________________________________________Family History-please check any of the boxes that apply and list the family or family members that condition applies to:Unknown Family HistoryAdopted: Family Member: _________________________________________Aneurysm: Family Member: ________________________________________Cancer: Type: ________: Family Member: ___________________________CVA: Family Member:_______________________________________________ Diabetes: Family Member:__________________________________________High Cholesterol: Family Member:_________________________________High Blood Pressure: Family Member:____________________________ Heart Attack: Family Member: _____________________________________Osteoporosis: Family Member:_____________________________________Peripheral Vascular Disease: Family Member:______________________Seizure Disorder: Family Member: ________________________________Sudden Cardiac Death: Family Member: __________________________Other:_________________________________________________________________ Family Member:______________________________________________Allergies-please list any allergies to any medications you may have:_______________________________________________________________________________________________________________________________________________________________________________________________________________Please indicate the Pharmacy Name & Number you prefer to use-__________________________________Please list your height and weight:Height:____________Wt:______________________Social History-please check any of the boxes that apply:Tobacco Use:Non smokerSmokerHow many packs a day:DipHow many years:Chewing tobaccoQuit date:Alcohol Use: Non DrinkerSociallyDailyIllegal Drug Use:AnalgesicsCocaineCrack CocaineHeroinMarijuana NarcoticsMethamphetamineOther:____________________Martial Status:SingleMarriedSignificant OtherDivorcedWidowedOther:________________Employment:Full TimePart TimeSelf EmployedRetiredUnemployedDisabledOther:______________Occupation:Please List: _________________________________________________________Medication History -please list any medications you are currently taking and why:DO YOU TAKE ANY BLOOD THINNERS? YES/ NOIF SO, what are they?Name of Medication:Why are you taking it?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PATIENT SIGNATURE:_________________________________________________________________ DATE ______________________________ ................
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