PatientPop



4501666344529Your blood work panel MUST include the following tests: Estradiol FSH Testosterone, Total TSH T4, Total T3, Free T.P.O. Thyroid Peroxidase Antibodies Vitamin D, 25-Hydroxy Vitamin B12 CBC (Complete Blood Count CMP (Comprehensive Metabolic Panel) Homocysteine00Your blood work panel MUST include the following tests: Estradiol FSH Testosterone, Total TSH T4, Total T3, Free T.P.O. Thyroid Peroxidase Antibodies Vitamin D, 25-Hydroxy Vitamin B12 CBC (Complete Blood Count CMP (Comprehensive Metabolic Panel) Homocysteine365760196336002273300596900New Patient Package (Female)00New Patient Package (Female)4445001489075Whether you are a new patient interested in the benefits of advanced hormone replacement therapy or an existing patient who is interested in improving your Quality of Life, we look forward to speaking with you and evaluating whether or not BioTE pellet therapy may be right for you.00Whether you are a new patient interested in the benefits of advanced hormone replacement therapy or an existing patient who is interested in improving your Quality of Life, we look forward to speaking with you and evaluating whether or not BioTE pellet therapy may be right for you.4445002484120Please take the time to read this introductory packet and answer the questions as completely as possible. Pay particular attention to the Symptom Assessment Checklist, as it’s important that our office understands the symptoms you may be experiencing today, and to what degree, so that we can approach your individual treatment plan, accordingly. Additionally, please take a BioTE brochure from our reception area or exam room and visit to learn more.00Please take the time to read this introductory packet and answer the questions as completely as possible. Pay particular attention to the Symptom Assessment Checklist, as it’s important that our office understands the symptoms you may be experiencing today, and to what degree, so that we can approach your individual treatment plan, accordingly. Additionally, please take a BioTE brochure from our reception area or exam room and visit to learn more.4445003802380To determine if you are a candidate for bio-identical hormone replacement pellet therapy, we will need the following:00To determine if you are a candidate for bio-identical hormone replacement pellet therapy, we will need the following:6972304298950???00???9931404293235Updated Laboratory Values = 1st Step in the treatment process (ask our office how) Updated Medical HistoryCompleted Symptom Assessment Checklist00Updated Laboratory Values = 1st Step in the treatment process (ask our office how) Updated Medical HistoryCompleted Symptom Assessment Checklist4445005038725Your advanced hormone lab panels may take approximately 2 weeks to be received by our office. We will then schedule an office visit (consult) to review your lab panels, medical history and symptom checklist, and of course address questions you may have about advanced hormone replacement pellet therapy. If you are a candidate and decide to move forward with BioTE therapy, we will most likely be able to perform the very simple and painless procedure in just a few minutes in our office that same day.Female Post Insertions Labs00Your advanced hormone lab panels may take approximately 2 weeks to be received by our office. We will then schedule an office visit (consult) to review your lab panels, medical history and symptom checklist, and of course address questions you may have about advanced hormone replacement pellet therapy. If you are a candidate and decide to move forward with BioTE therapy, we will most likely be able to perform the very simple and painless procedure in just a few minutes in our office that same day.Female Post Insertions Labs41021006336665Needed at 6 Weeks: FSH Testosterone, Total Estradiol TSH, T4 Total, T3 Total(Needed only if you’ve been prescribed Thyroid medication at visit)00Needed at 6 Weeks: FSH Testosterone, Total Estradiol TSH, T4 Total, T3 Total(Needed only if you’ve been prescribed Thyroid medication at visit)42367206608445004236720682180500579120688467000423672070338950057912070643750042367207247255005791207268210005791207472680005791207677150005791207880985005791208085455005791208289290005791208493760005791208696325005791208900795005791209103360002239107380413Female Patient Questionnaire & History00Female Patient Questionnaire & History3657605880294In the event we cannot contact you by the mean’s you’ve provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment. By giving the information below you are giving us permission to speak with your spouse or significant other about your treatment.00In the event we cannot contact you by the mean’s you’ve provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment. By giving the information below you are giving us permission to speak with your spouse or significant other about your treatment.3710361968990013970009182100( ) I smoke cigarettes/cigars/vape ( ) I am sexually active ( ) I have completed my family00( ) I smoke cigarettes/cigars/vape ( ) I am sexually active ( ) I have completed my family34290046549503683001465580Name: Today’s Date: 00Name: Today’s Date: 13589001642110(Last)00(Last)27305001642110(First)00(First)41021001642110(Middle)00(Middle)3683001862455Date of Birth:Age:Weight:Profession: __00Date of Birth:Age:Weight:Profession: __3683002311400Home Address: 00Home Address: 3683002680335City:State:Zip: 00City:State:Zip: 3683003050540Home Phone:Cell Phone:Work: 00Home Phone:Cell Phone:Work: 3683003414395E-Mail Address:May we contact you via E-Mail? ( ) YES ( ) NOIn Case of Emergency Contact:Relationship: 00E-Mail Address:May we contact you via E-Mail? ( ) YES ( ) NOIn Case of Emergency Contact:Relationship: 3683004094480Home Phone:Cell Phone:Work: 00Home Phone:Cell Phone:Work: 3683004463415Primary Care Physician’s Name:Phone: 00Primary Care Physician’s Name:Phone: 3683004833620Address: 00Address: 21031205010150Address00Address42176705010150City00City60483755010150State00State66897255010150Zip00Zip3683005391150Marital Status (check one):00Marital Status (check one):19215105391150(00(21120105391150) Married00) Married28435305391150(00(30340305391150) Divorced00) Divorced38404805391150(00(40309805391150) Widow00) Widow47364655391150(00(49269655391150) Living with Partner00) Living with Partner62674505391150(00(64585855391150) Single00) Single3683006813550Spouse’s Name:Relationship: 00Spouse’s Name:Relationship: 3683007219950Home Phone:Cell Phone:Work: 00Home Phone:Cell Phone:Work: 8255007605395Insurance: Insured Name:DOB:SS# 00Insurance: Insured Name:DOB:SS# 8255008017510Relation to Patient:Employer:Primary Insurance: 00Relation to Patient:Employer:Primary Insurance: 8255008423910Claims Address:City/State/Zip 00Claims Address:City/State/Zip 8255008829675ID#Group# 00ID#Group# 3683009180830Social History:00Social History:720725146939000620585514693900011518901876425003124200187642500472440018764250061112401876425001275715231521000659765268414500504126526841450061506102684145001191895305435000366966530543500057531003054350001269365342328500211709037280850056267353728085001191895409829000366966540982900057238904098290002136775446722500560705044672250093726048374300013074656817360005113020681736000119189572243950036696657224395005722620722439500240347576142850048875957614285005934710761428500194183080213200035477458021320005822950802132000176784084283550053657508428355001083310883348500433959088334850070231091903550038709605166360(((((((((((((((((((00(((((((((((((((((((2222500520065Medical History00Medical History40655635162842) High blood pressure) High cholesterol.) Uterine Fibroids) Polycystic Ovarian Syndrome (PCOS)) Stroke and/or heart attack.) Heart Bypass/Heart Disease) Blood clot and/or a pulmonary emboli) Arrhythmia/Irregular Heartbeat) Any form of Hepatitis or HIV) Lupus or other Autoimmune disease) Fibromyalgia) Chronic liver disease (hepatitis, fatty liver, cirrhosis)) Seizure Disorder/Epilepsy) Chronic Kidney Disease) Diabetes) Thyroid disease) Arthritis) Depression/anxiety) Cancer (type): & Year00) High blood pressure) High cholesterol.) Uterine Fibroids) Polycystic Ovarian Syndrome (PCOS)) Stroke and/or heart attack.) Heart Bypass/Heart Disease) Blood clot and/or a pulmonary emboli) Arrhythmia/Irregular Heartbeat) Any form of Hepatitis or HIV) Lupus or other Autoimmune disease) Fibromyalgia) Chronic liver disease (hepatitis, fatty liver, cirrhosis)) Seizure Disorder/Epilepsy) Chronic Kidney Disease) Diabetes) Thyroid disease) Arthritis) Depression/anxiety) Cancer (type): & Year5627098299938) Menopause) Hysterectomy) Tubal Ligation) Birth Control Pills) Vasectomy00) Menopause) Hysterectomy) Tubal Ligation) Birth Control Pills) Vasectomy3653201823920034290044009603683001348105Any known drug/environmental (i.e. tape/adhesive) allergies: 00Any known drug/environmental (i.e. tape/adhesive) allergies: 3683001734820Have you ever had any issues with anesthesia?00Have you ever had any issues with anesthesia?33216851734820(00(35274251734820) Yes00) Yes41084501734820(00(43141901734820) No00) No3683002001520If yes please explain: 00If yes please explain: 3683002369820Medications Currently Taking: 00Medications Currently Taking: 3683002727960Current Hormone Replacement Therapy: _ _00Current Hormone Replacement Therapy: _ _3683003095625Past Hormone Replacement Therapy: 00Past Hormone Replacement Therapy: 3683003474720Nutritional/Vitamin Supplements: _00Nutritional/Vitamin Supplements: _3683003843655Surgeries, list all and when: 00Surgeries, list all and when: 3683004200525Last menstrual cycle (estimate year if unknown): 00Last menstrual cycle (estimate year if unknown): 3683004579620Other Pertinent Information: 00Other Pertinent Information: 3683004876800Preventative Medical Care:Date of last pap smear: _ 00Preventative Medical Care:Date of last pap smear: _ 38627054878705Please mark any Medical Illnesses:00Please mark any Medical Illnesses:3683005433060Was it normal?00Was it normal?14566905433060(00(16624305433060) Yes00) Yes22428205433060(00(24485605433060) No00) No3683005687695Date of last Mammogram:00Date of last Mammogram:20173955687695 00 3683005942330Was it normal?00Was it normal?14566905942330(00(16624305942330) Yes00) Yes22428205942330(00(24485605942330) No00) No3683006158865Do you have a history of:00Do you have a history of:3683006387465((((00((((5664206387465) Breast Cancer) Uterine Cancer) Ovarian Cancer) None of Above00) Breast Cancer) Uterine Cancer) Ovarian Cancer) None of Above3683007219315Have you had:00Have you had:3683007477125(((00(((5740407477125) Hysterectomy with removal of ovaries.) Hysterectomy (removal of uterus only)) Oophorectomy (Removal of Ovaries only)00) Hysterectomy with removal of ovaries.) Hysterectomy (removal of uterus only)) Oophorectomy (Removal of Ovaries only)3683008058785Birth Control Method:00Birth Control Method:3683008301355(((((00(((((457644513830300016490952016760002228215238569500295973527546300034201102754630002726690312166000245491034905950020586703859530003418205422656000214122045954950019062705195570002030095570357000502285091459050032092903378200IUD00IUD36753803378200Menopause00Menopause45548553378200Tubal ligation00Tubal ligation55245003378200Vasectomy00Vasectomy63576203378737Other00Other2952753375562AbstinenceBirth control pillHysterectomy00AbstinenceBirth control pillHysterectomy2954221828801Pellets are bioidentical, structurally equivalent to the hormones your body naturally produces. Estrogen and testosterone are made in your ovaries and adrenal glands. Even prior to menopause, testosterone levels start to decrease. Bio-identical hormones have the same effects on your body as your own naturally occurring hormones did when you were producing them at adequate levels. Bio-identical hormone pellets are plant derived and are FDA monitored but not FDA approved for female hormone replacement. The pellet method of hormone replacement has been used in Europe and Canada for many years and by select practitioners in the United States.Patients who are pre-menopausal are advised to continue reliable birth control while participating in pellet hormone replacement therapy. Testosterone is category X (could cause birth defects based on human/animal studies) and should not be given to pregnant women.My birth control method is: (please circle)00Pellets are bioidentical, structurally equivalent to the hormones your body naturally produces. Estrogen and testosterone are made in your ovaries and adrenal glands. Even prior to menopause, testosterone levels start to decrease. Bio-identical hormones have the same effects on your body as your own naturally occurring hormones did when you were producing them at adequate levels. Bio-identical hormone pellets are plant derived and are FDA monitored but not FDA approved for female hormone replacement. The pellet method of hormone replacement has been used in Europe and Canada for many years and by select practitioners in the United States.Patients who are pre-menopausal are advised to continue reliable birth control while participating in pellet hormone replacement therapy. Testosterone is category X (could cause birth defects based on human/animal studies) and should not be given to pregnant women.My birth control method is: (please circle)2289175379095Female Testosterone and/or Estradiol Pellet Insertion Consent Form00Female Testosterone and/or Estradiol Pellet Insertion Consent Form363757196215003429004527960303530876681000307657587668100061836308766810002921001408430Name:Today’s Date: 00Name:Today’s Date: 8318501558925(Last)00(Last)22866351558925(First)00(First)38519101558925(Middle)00(Middle)2921003743325CONSENT FOR TREATMENT: I consent to the insertion of testosterone and/or estradiol pellets in my hip/abdomen. I have been informed that I may experience any of the complications to this procedure as described below. Surgical risks are the same as for any minor medical procedure and are included in the list of overall risks: Bleeding, bruising, swelling, infection and pain; extrusion of pellets; hyper sexuality (overactive Libido); lack of effect (from lack of absorption); breast tenderness and swelling; increase in hair growth on the face; acne; water retention; increased growth of estrogen dependent tumors (endometrial cancer, breast cancer); birth defects in babies exposed to testosterone during their gestation; change in voice (which is reversible); clitoral enlargement (which is reversible). The estradiol dosage that I may receive can aggravate fibroids or polyps, if they exist, and can cause bleeding. Testosterone therapy may increase one’s hemoglobin and hematocrit. This elevation can be seen with a blood test. Thus, a complete blood count should be done at least annually. This condition can be reversed simply by donating blood periodically.00CONSENT FOR TREATMENT: I consent to the insertion of testosterone and/or estradiol pellets in my hip/abdomen. I have been informed that I may experience any of the complications to this procedure as described below. Surgical risks are the same as for any minor medical procedure and are included in the list of overall risks: Bleeding, bruising, swelling, infection and pain; extrusion of pellets; hyper sexuality (overactive Libido); lack of effect (from lack of absorption); breast tenderness and swelling; increase in hair growth on the face; acne; water retention; increased growth of estrogen dependent tumors (endometrial cancer, breast cancer); birth defects in babies exposed to testosterone during their gestation; change in voice (which is reversible); clitoral enlargement (which is reversible). The estradiol dosage that I may receive can aggravate fibroids or polyps, if they exist, and can cause bleeding. Testosterone therapy may increase one’s hemoglobin and hematocrit. This elevation can be seen with a blood test. Thus, a complete blood count should be done at least annually. This condition can be reversed simply by donating blood periodically.2921005252085BENEFITS OF TESTOSTERONE PELLETS INCLUDE: Increased libido, energy, and sense of well-being. Increased muscle mass and strength and stamina. Decreased frequency and severity of migraine headaches. Decrease in mood swings, anxiety and irritability. Decreased visceral fat. Decrease in risk or severity of diabetes. Decreased risk of heart disease. Decreased risk of Alzheimer’s and dementia00BENEFITS OF TESTOSTERONE PELLETS INCLUDE: Increased libido, energy, and sense of well-being. Increased muscle mass and strength and stamina. Decreased frequency and severity of migraine headaches. Decrease in mood swings, anxiety and irritability. Decreased visceral fat. Decrease in risk or severity of diabetes. Decreased risk of heart disease. Decreased risk of Alzheimer’s and dementia2908305838825BENEFITS OF ESTRADIOL PELLETS INCLUDE: Decreased vaginal dryness. Increased skin elasticity. Decreased hot flashes, mood swings, depression, anxiety, and headaches caused by hormone fluctuations. Increase and maintenance of bone density. May prevent atherosclerosis (hardening and narrowing of the blood vessels) and complications associated with coronary artery disease. Decrease risk of Alzheimer’s and dementia (neuroprotection).I have read and understand the above. I have been encouraged and have had the opportunity to ask any questions regarding pellet therapy. All of my questions have been answered to my satisfaction. I further acknowledge that there may be risks of testosterone and or estrogen therapy that we do not yet know, at this time, and that the risks and benefits of this treatment have been explained to me and I have been informed that I may experience complications, including one or more of those listed above. I accept these risks and benefits and I consent to the insertion of hormone pellets under my skin. This consent is ongoing for this and all future pellet insertions.I understand that payment is due in full at the time of service. I also understand that it is my responsibility to submit a claim to my insurance company for possible reimbursement. I have been advised that most insurance companies do not consider pellet therapy to be a covered benefit and my insurance company may not reimburse me, depending on my coverage. I acknowledge that my provider has no contracts with any insurance company and is not contractually obligated to pre-certify treatment with my insurance company or answer letters of appeal.00BENEFITS OF ESTRADIOL PELLETS INCLUDE: Decreased vaginal dryness. Increased skin elasticity. Decreased hot flashes, mood swings, depression, anxiety, and headaches caused by hormone fluctuations. Increase and maintenance of bone density. May prevent atherosclerosis (hardening and narrowing of the blood vessels) and complications associated with coronary artery disease. Decrease risk of Alzheimer’s and dementia (neuroprotection).I have read and understand the above. I have been encouraged and have had the opportunity to ask any questions regarding pellet therapy. All of my questions have been answered to my satisfaction. I further acknowledge that there may be risks of testosterone and or estrogen therapy that we do not yet know, at this time, and that the risks and benefits of this treatment have been explained to me and I have been informed that I may experience complications, including one or more of those listed above. I accept these risks and benefits and I consent to the insertion of hormone pellets under my skin. This consent is ongoing for this and all future pellet insertions.I understand that payment is due in full at the time of service. I also understand that it is my responsibility to submit a claim to my insurance company for possible reimbursement. I have been advised that most insurance companies do not consider pellet therapy to be a covered benefit and my insurance company may not reimburse me, depending on my coverage. I acknowledge that my provider has no contracts with any insurance company and is not contractually obligated to pre-certify treatment with my insurance company or answer letters of appeal.2908308774430Print Name00Print Name30778458774430Signature00Signature61791858774430Today’s Date00Today’s Date6858001399540005861050139954000303530862711000307657586271100061836308627110002191727558800Female Symptom Assessment Checklist00Female Symptom Assessment Checklist3793882109670034290046549604445001633855Name: _00Name: _57086501633855Date: 00Date: 3486152310765Please mark any Symptoms:00Please mark any Symptoms:42716452493010NEVER00NEVER51460402493010MILD00MILD58851802484120MODERATE00MODERATE68884802487295SEVERE00SEVERE3435352745740FatigueMemory Loss / Confusion Decreased Sex Drive / Libido Sleep ProblemsMood Changes / Irritability Weight GainVaginal DrynessHot Flashes / Night Sweats Cold All The TimeJoint Pain00FatigueMemory Loss / Confusion Decreased Sex Drive / Libido Sleep ProblemsMood Changes / Irritability Weight GainVaginal DrynessHot Flashes / Night Sweats Cold All The TimeJoint Pain43002202751455((((((((((00((((((((((45021502751455))))))))))00))))))))))51435002751455((((((((((00((((((((((53447952751455))))))))))00))))))))))60090052751455((((((((((00((((((((((62109352751455))))))))))00))))))))))69411852751455((((((((((00((((((((((71431152751455))))))))))00))))))))))3917956212205Please mark any Family History:00Please mark any Family History:43834056512560YES00YES52412906512560NO00NO3867156760210Heart DiseaseDiabetes Osteoporosis Alzheimer's Disease Breast Cancer00Heart DiseaseDiabetes Osteoporosis Alzheimer's Disease Breast Cancer43440356783070(((((00(((((45453306783070)))))00)))))51866806783070(((((00(((((53886106783070)))))00)))))90551016497300060947301649730002290738463843Hormone Replacement Fee Acknowledgment00Hormone Replacement Fee Acknowledgment3371852812070059944008369300Today’s Date00Today’s Date5080008369300Print Name00Print Name33274008369300Signature00Signature9652003505200New Patient Consult FeeFemale Hormone Pellet Insertion FeeMale Hormone Pellet Insertion Fee Male Pellet Insertion Fee (>2000mg)00New Patient Consult FeeFemale Hormone Pellet Insertion FeeMale Hormone Pellet Insertion Fee Male Pellet Insertion Fee (>2000mg)3429004654960521335824674500333121082467450059499508246745005086351981200You will be responsible for payment in full at the time of your procedure. Although more insurance companiesare reimbursing patients for the BioTE? Medical Hormone Replacement Therapy, there is no guarantee.00You will be responsible for payment in full at the time of your procedure. Although more insurance companiesare reimbursing patients for the BioTE? Medical Hormone Replacement Therapy, there is no guarantee.5086352522220We will give you paperwork to send to your insurance company to file for reimbursement upon request.00We will give you paperwork to send to your insurance company to file for reimbursement upon request.55378353498850$125$330$625$72500$125$330$625$7259290056017895We accept the following forms of payment:Master Card, Visa, Discover, American Express, Personal Checks, HSA, FSA, and Cash.00We accept the following forms of payment:Master Card, Visa, Discover, American Express, Personal Checks, HSA, FSA, and Cash.521335810704500333121081070450059499508107045003683981968020033020047819502270760418465Hormone Therapy Dosing Assistance Form00Hormone Therapy Dosing Assistance Form4445001397635Name: 00Name: 4445001732915Weight: 00Weight: 21710651732915DOB: 00DOB: 40805101732915Last 4 SSN:00Last 4 SSN:47942501732915 00 3924302269490Please mark any Medical History:00Please mark any Medical History:43834052560955YES00YES52412902560955NO00NO3848102805430HysterectomyBreast Cancer Still MenstruatingCurrently on Thyroid Medication Hashimoto's Thyroiditis Fibricystic Breast DiseasePCOSMigraine Headaches History of Fibroids / Polyps EpilepsyCurrently on HRTCurrently Pregnant / Trying to Conceive Currently on Birth Control00HysterectomyBreast Cancer Still MenstruatingCurrently on Thyroid Medication Hashimoto's Thyroiditis Fibricystic Breast DiseasePCOSMigraine Headaches History of Fibroids / Polyps EpilepsyCurrently on HRTCurrently Pregnant / Trying to Conceive Currently on Birth Control43440352831465(((((((((((((00(((((((((((((45459652831465)))))))))))))00)))))))))))))51873152831465(((((((((((((00(((((((((((((53892452831465)))))))))))))00)))))))))))))43497507070725Social History00Social History3867157179945Are You Still Having Any of the Following Symptoms?00Are You Still Having Any of the Following Symptoms?43497507509510How often do you exercise? (Check One)00How often do you exercise? (Check One)589915077908154-7 HRS / WK004-7 HRS / WK434848078003400 HRS000 HRS501777078003401-3 HRS / WK001-3 HRS / WK68059307795260>8 HRS / WK00>8 HRS / WK20840707809230YES00YES29419557809230NO00NO60750458068945(00(62769758068945)00)3867158077835AcneIrregular Bleeding Heavy Bleeding Facial HairBreast Tenderness00AcneIrregular Bleeding Heavy Bleeding Facial HairBreast Tenderness20447008080375(((((00(((((22459958080375)))))00)))))28873458080375(((((00(((((30892758080375)))))00)))))43662608075295(00(45681908075295)00)51974758075295(00(53994058075295)00)69996058075295(00(72015358075295)00)43707058627745Do You Smoke? (Check One)00Do You Smoke? (Check One)44202359023985YES00YES52812959023985NO00NO43872159299575(00(45885109299575)00)52184309299575(00(54203609299575)00)949325141351000960120174879000252222017487900048069501748790004572003101772Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.We agree to provide patients with access to their records in accordance with state and federal laws.We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.00Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.We agree to provide patients with access to their records in accordance with state and federal laws.We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.5086358121853I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.00I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.4474721400783The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. We have adopted the following policies:00The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. We have adopted the following policies:2353945621665HIPAA Information & Consent Form00HIPAA Information & Consent Form4497262110870059944009131300Today’s Date00Today’s Date33274009131300Signature00Signature5080009131300Print Name00Print Name34290046549605213359016365003331210901636500594995090163650052133588766650033312108876665005949950887666500 ................
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