1050 E. Hwy 114, Ste 100 Southlake, TX / Welcome to Your Medical Home 10/22/14

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1 1050 E. Hwy 114, Ste 100 Southlake, TX / Welcome to Your Medical Home 10/22/14 A medical home is a team approach to providing total health care. Your medical home will include your health care provider, others who support you, and most importantly, you. You are the most important person on the health care team. Patient-centered is a way of saying that you are the focus of our health care. Your medical home can: Help you manage your health care by using evidence based care and selfmanagement support Help answer your health questions Listen to your concerns Work with other medical experts if necessary Coordinate your care through additional services Encourage you to play an active part in your own health care What can YOU do to help? 1. Be an active team player Talk with your team about your health questions Share your past health care successes and challenges Tell your team about other health care professionals who care for you Tell your team how you feel about the care you are getting from them 2. Take care of your health Follow the health care plan you and your team have talked about. Make sure you understand how to follow the plan. Set goals you can reach. Once you begin to see results, you and your team can discuss adding new goals. 3. Talk openly with your team Tell your team if you are having trouble sticking with your care plan Speak up if your care plan is not working. Tell your team what is not working so together you can make changes if needed. What can YOU expect? In a medical home, you and your team will work together. As an active member of the team, you will have a chance to explain the things that are really important to you o Your team can answer questions and help you better understand your health care needs o If you need to get help from other doctors, your team can support you every step of the way. o When you have concerns about your health, your medical home team will work with you to determine the best way to deal with them.

2 Together, you and your team can work on a plan that: o Is personalized or created just for you o Is coordinated with other health care providers o Connects you with your health care team Working with your team may improve the quality of your health care and shorten the time it takes to get that care. During your appointment, use this handy checklist Write down the names or your team members Use a list of questions you ve written down. Ask you most important question first. Even if you cannot get all of your answers on the first visit, having a list will help you keep track of the answers Talk with your team about what health issue to work on first. Use your own words to repeat back the things you ve discussed with your team. This way, both you and your team will know the information is clear. Before you leave the office, be sure you know the things you need to work on before your next appointment. We have outlined a few of our office policies that help us serve you better. For more information please visit us at Clinic Hours We are open Monday through Friday 8:00am - 12:00pm and 1:30pm - 5:00pm Appointments Appointments can be made during regular business hours. If you are unable to keep your appointment, we ask that you be considerate of other patients who may need to be seen by canceling as soon as possible. We may bill you a cancellation fee for a missed appointment without proper notification. If you arrive late for your appointment, we will make every attempt to see you; however your appointment may have to be rescheduled. Telephone Calls/Web messages for the Providers or Medical Assistants Our phones are answered and web messages are checked by our staff from 8:30 to 5:00. Our trained staff accepts all calls/messages from patients, enabling the provider to spend more time with the patients in the office. A medical assistant will return all calls/messages received before 4:00 pm by the end of the day. Calls/messages received after 4:00pm will be returned by the end of the next business morning. After hours Emergency Calls Our providers are always available after office hours, 5:00 pm to 8:30 am, for emergency calls. Night and weekend coverage is shared with other qualified area physicians. Call our main number, 817/ for instructions. In a life-threatening situation, go to the nearest Emergency Room or call 911. Prescriptions Your medical record is needed to determine whether a refill should be issued, therefore refills cannot be approved after normal business hours. During your visit your Doctor will give you prescriptions in amounts to last until you need to be seen again. Follow up appointments are scheduled so that your provider can monitor your condition and adjust medications

3 accordingly. To ensure appointment availability, please make this appointment at the time of your current visit or at the time you get your last refill. Prescription requests received after 4pm will be processed by the end of the next business day. If you do find yourself in need of more medication prior to your appointment, please call your pharmacy, who will call us for any additional refills. Limited refills may be given to allow time for you to make your appointment. Referrals Some managed care plans require your primary care doctor to obtain authorization to be referred to another provider. If your managed care plan requires this, we will obtain authorization from your insurance company within 3 business days. Please do not make an appointment with the specialist until you have received a call from our referral department. Outpatient Procedures We will obtain authorization from your insurance company and you will be contacted by the facility to which you are being sent to within 5 business days to schedule your procedure. Your results will be discussed at your follow-up appointment. Lab Results Acute illness lab results: o All Labs Results will be discussed at your follow-up appointment. Chronic disease results: o Labs are drawn 1 week prior to your appointment with the Provider. Results are reviewed at this appointment. Physical lab results (including pap smears): o Labs are drawn after your physical exam either the same day or the next morning. A physical follow up appointment should be made for 2-4 weeks after the physical. Results are reviewed at this follow up appointment. Surgical Biopsy result: o You will either be called in days or the results will be reviewed during suture removal appointment Treatment of a Minor A minor is a person under the age of 18 who has never been married and never been declared an adult by a court. Generally, minors do not have the legal capacity to consent to medical treatment. In order for us to treat a minor we must have a written consent from a parent or legal guardian including a statement as to the nature of the medical treatment to be given on a specific day. Minors age 15 and under MUST be accompanied by an adult (18yrs old and older) With the written consent, we will perform the following: Examination X-Rays Other testing Noninvasive procedures

4 We will not perform: Invasive procedures Immunizations Injections Lab Draws Managed Care We accept dozens of insurance plans with various deductibles, co-pays, and coverage s. We cannot know all of the coverage limitations and rules of your plan. It is important that you read and understand the provisions of your insurance policy. Co-Pays All co-pay payments are due at check in. Please bring your insurance card to every visit. Responsibility for ensuring Insurance Coverage You are responsible for ensuring that we are providers on your insurance plan and for knowing what services you have coverage for including but not limited to office visits, labs, x-ray, procedures, physicals and immunizations. You will be responsible for paying for all services not covered by your insurance plan. Motor Vehicle Accidents (MVA) We do not file charges for MVA insurance policies. All charges for services rendered due to a MVA are payable in full at the time of your visit. You will need to submit your charges and seek reimbursement from the MVA insurance company. Third Party Liability Third party liability means that someone else s insurance is to cover your illness/injury. For example, a fall at a grocery store, where the grocery store s insurance will pay for your medical bills. We do not file charges for payment to attorneys or any other third party payor. All charges for services rendered are payable in full at the time of your visit. You will need to submit your charges and seek reimbursement from the third party insurance payor. Workman s Compensation We do not file workman s compensation insurance, therefore we cannot treat you for any work related illness or injury. Due to State Laws, you could be denied benefits if you claim your condition is not work related but it actually is.

5 You are invited to join our HIPAA compliant, secure, all-in-one personal 24/7 anywhere, anytime health record and patient portal that you can access via computer, smart phone or smart pad. We encourage you to use the portal so you may save hold time and avoid telephone tag: To request a non-urgent appointment o You will receive text and/or alerts and reminders To securely contact o Your provider with non-urgent questions o Your provider for refill requests o Our front desk to update your demographic information To allow you to check your personal demographic information To view past test and lab results To receive care reminders Getting Started is Easy!!! All you need to do is sign the Invitation Form at your appointment. That s it!! Within a day or two you will receive an invitation via to complete the connection to your personal health record and all of the benefits of the 24/7 patient portal.

6 Notice of Privacy Practices Form 7.20 North Country Family Practice This notice describes how medical information about you may be used and disclosed and how you can gain access to this information. Please review it carefully. Protected health information (PHI), about you, is maintained as a record of your contacts or visits for healthcare services with our practice. Specifically, PHI is information about you, including demographic information (i.e., name, address, phone, etc.), that may identify you and relates to your past, present or future physical or mental health condition and related healthcare services. Our practice is required to follow specific rules on maintaining the confidentiality of your PHI, using your information, and disclosing or sharing this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law. If you have any questions about this Notice, please contact our Privacy Manager at Dwight Rector. Your Rights Under The Privacy Rule Following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any questions with our staff. You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices - We are required to follow the terms of this notice. We reserve the right to change the terms of our notice, at any time. If needed, new versions of this notice will be effective for all PHI that we maintain at that time. Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment. The Notice will also be posted in a conspicuous place within the practice, and if such is maintained by the practice, on its web site. You have the right to authorize other use and disclosure - This means you have the right to authorize any use or disclosure of PHI that is not specified within this notice. For example, we would need your authorization to use or disclose your PHI for marketing purpose or for any use or disclosure of psychotherapy notes. You may revoke an authorization, at any time, in writing, except to the extent that your Healthcare Provider or our office has taken an action in reliance on the use or disclosure indicated in the authorization. North Country Family Practice Publication Date 01/01/2011 Effective Date 01/01/2011 page 1 of 5

7 You have the right to request an alternative means of confidential communication This means you have the right to ask us to contact you about medical matters using a method (i.e., , telephone, etc.), and to a destination (i.e., cell phone number, alternative address, etc.) designated by you. We will follow all reasonable requests. You must inform us in writing how you wish to be contacted (using a form provided by our practice). You have the right to inspect and copy your PHI - This means you may inspect and obtain a copy of PHI about you that is contained in your patient record. If your health record is maintained electronically, you will also have the right to request a copy in electronic format. We have the right to charge a reasonable fee for paper or electronic copies as established by professional, state, or federal guidelines. You have the right to request a restriction of your protected health information - This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases, we may deny your request for a restriction. You will have the right to request, in writing, that we restrict communication to your healthplan regarding a specific treatment or service that you, or someone on your behalf, has paid for, in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction. You may have the right to request an amendment to your protected health information - This means you may request an amendment of your protected health information for as long as we maintain this information. In certain cases, we may deny your request for an amendment. You have the right to request a disclosure accountability - This means that you may request a listing of disclosures that we have made, of your PHI, to entities or persons outside of our office. How We May Use or Disclose Protected Health Information Following are examples of uses and disclosures of your protected health information that we are permitted to make. These examples are not meant to be exhaustive, but to describe possible types of uses and disclosures. Treatment - We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that is involved in your care and treatment. For example, we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose PHI to other Healthcare Providers who may be involved in your care and treatment. North Country Family Practice Publication Date 01/01/2011 Effective Date 01/01/2011 page 2 of 5

8 Special Notices - We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may contact you by phone or other means to provide results from exams or tests and to provide information that describes or recommends treatment alternatives regarding your care. Also, we may contact you to provide information about health-related benefits and services offered by our office, for fund-raising activities; or with respect to a group health plan, to disclose information to the health plan sponsor. You will have the right to opt out of such special notices by notifying our office in writing. Payment - Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits. Healthcare Operations - We may use or disclose, as-needed, your PHI in order to support the business activities of our practice. This includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, and auditing functions. Regional Information Organization - The practice may elect to use a regional information organization or other such organization to facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations. OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES We may also use and disclose your PHI in the instances outlined below. To Others Involved in Your Healthcare - Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person, that you identify, your PHI that directly relates to that person s involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, of your general condition or death. If you are not present or able to agree or object to the use or disclosure of the PHI, then your Healthcare Provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is relevant to your healthcare will be disclosed. As Required By Law - We may use or disclose your PHI to the extent that is required by law. For Public Health - We may disclose your PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. North Country Family Practice Publication Date 01/01/2011 Effective Date 01/01/2011 page 3 of 5

9 For Communicable Diseases - We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. For Health Oversight - We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. In Cases of Abuse or Neglect - We may disclose your PHI to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your PHI if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. To The Food and Drug Administration - We may disclose your PHI to a person or company required by the Food and Drug Administration to report adverse events, to monitor product defects or problems, to report biologic product deviations, to track products, to enable product recalls, to make repairs or replacements, or to conduct post-marketing surveillance, as required. For Legal Proceedings - We may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process. To Law Enforcement - We may also disclose PHI, as long as applicable legal requirements are met, for law enforcement purposes. To Coroners, Funeral Directors, and Organ Donation - We may disclose PHI to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law, in order to permit the funeral director to carry out his/her duties. PHI may be used and disclosed for cadaveric organ, eye or tissue donation purposes. For Research - We may disclose your PHI to researchers when an institutional review board has reviewed and approved the research proposal and established protocols to ensure the privacy of your PHI. In Cases of Criminal Activity - Consistent with applicable federal and state laws, we may disclose your PHI if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose PHI, if it is necessary for law enforcement authorities, to identify or apprehend an individual. North Country Family Practice Publication Date 01/01/2011 Effective Date 01/01/2011 page 4 of 5

10 For Military Activity and National Security - When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel: (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits; or (3) to foreign military authority if you are a member of that foreign military service. For Workers Compensation - Your PHI may be disclosed as authorized to comply with workers compensation laws and other similar legally-established programs. When an Inmate - We may use or disclose your PHI if you are an inmate of a correctional facility and your Healthcare Provider created or received your protected health information in the course of providing care to you. Required Uses and Disclosures - Under the law, we must make disclosures about you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the Privacy Rule. Privacy Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Manager at Dwight Rector. North Country Family Practice Publication Date 01/01/2011 Effective Date 01/01/2011 page 5 of 5

11 We ask that you complete the following paperwork and return to us as soon as possible so that we can prepare your chart ahead of time which saves you time when you arrive for your appointment. If possible, return the paperwork at least 2 days prior to your appointment. If you complete the paperwork online, you will still need to the completed forms to us. If you are unable to do so, please bring the completed paperwork with you to your appointment. newpatient@northcountryfamilypractice.com Fax: 817/ Mail: 1050 E. Hwy 114, Ste 100, Southlake, TX 76092

12 Welcome to North Country Family Practice! Date: Please let us know how you first heard about our office? What made you pick up the phone and call us to make an appointment? Select all that apply. Word of mouth: Friend, Neighbor, Co-Worker, Family, etc. Drive by and saw sign/building Insurance website Facebook Website: If so, what search engine did use: Google Yahoo Bing Other: What did you search for: Other: Why did you change from your current doctor/clinic? New to the area Didn t have other current doctor/clinic Insurance change: Doctor no longer on plan, got a new plan, etc. Unhappy with last doctor/clinic Why? Other

13 Date: PATIENT INFORMATION: NORTH COUNTRY FAMILY PRACTICE, P.A. v7/14/15 Pt. # Name: Date of Birth: Sex: Male Female Address: City: State Zip: Home Phone: Cell Phone: Work Phone: Please check the box for your primary number Address: Patient s SS#: Marital Status: Preferred Language: English Spanish Other: Ethnicity: Hispanic/Latino Not Hispanic/Latino Decline to answer Race: White Black/AfricanAmerican Asian NativeHawaiian Other PacificIslander AmericanIndian/Alaska Native More than 1 race Decline to Answer Emergency contact name: Phone #: Relationship: PRIMARY INSURANCE COMPANY: Primary Insurance Policy Holder s Information [ ] Same as Patient Complete below if different than patient Relationship to Patient: Name: Date of Birth: Sex: Male Female Insured/Subscriber SS#: SECONDARY INSURANCE COMPANY: Secondary Insurance Policy Holders Information [ ] Same as Patient [ ] Same as Primary Complete below if different than patient Relationship to Patient: Name: Date of Birth: Sex: Male Female Insured/Subscriber SS#: PARENT OR LEGAL GUARDIAN INFORMATION: Relationship to Patient: Name: Home Phone: Cell Phone: Work Phone: Please check the box for your primary number NORTH COUNTRY FAMILY PRACTICE, P.A.

14 CONSENT FOR TREATMENT USE OF PHYSICIANS ASSISTANTS AND NURSE PRACTITIONERS - RELEASE OF INFORMATION I consent to treatment for the care of the patient indicated on this form. Authorization is hereby granted to release information as may be necessary to process and complete my insurance claim. This facility has on staff both physician assistants and nurse practitioners to assist in the delivery of medical care. Physician assistants and nurse practitioners are not doctors. They both however do have advanced education and training. Under the supervision of a physician both can diagnose, treat and monitor common acute and chronic diseases as well as provide health maintenance care. Supervision does not require the constant physical presence of the supervising physician, but rather overseeing the activities of and accepting responsibility for the medical services provided. I have read the above, and hereby consent to the services of a nurse practitioner and/or a physician s assistant. I understand that at any time I can choose to see a physician instead of a nurse practitioner and/or a physician s assistant. It is my responsibility to schedule with the provider of my choosing. X Date: Signed: ASSIGNMENT OF INSURANCE BENEFITS I hereby authorize payment of medical benefits to be paid directly to North Country Family Practice, P.A. for services rendered. X Date: Signed: We are on several managed care plans that we will be happy to file for you. As a condition of accepting your insurance in lieu of payment, all co-pays and deductible amounts are due at the time of service. Payment from your insurance is expected within 45 days. After 45 days, we will look to you for payment in full. If you are not on one of the managed care programs that we are providers for, payment in full is expected at the time of service. We will provide you a bill with the information necessary for you to file your insurance claim. It is up to you to know your insurance coverage. If services are denied payment from your insurance as noncovered or you have failed to give us your correct insurance information, you will be responsible to pay for those charges. X Date: Signed:

15 North Country Family Practice Personal and Family History Form 8/3/15 Pt. # Name: Date of birth: Date: Current or Past Medical Problems: (please circle all that apply) Anemia Diabetes Juvenile Elevated Cholesterol Urinary Incontinence Arthritis Diabetes Gestational Hypertension UTI Asthma Chronic Ear Infections Hyperthyroidism Varicose Veins Cancer: Endometriosis Hypothyroidism Other: Cataracts Gastro-Esophageal Reflux Kidney Stones Stroke Glaucoma Meningitis Cirrhosis Gout Muscular Dystrophy Colitis Headaches Multiple Sclerosis Congestive Heart Failure Heart Disease Osteoporosis Constipation Heart Attack Peptic Ulcer Disease Chronic Lung Disease Hemorrhoids Pneumonia Depression HIV Sexually Transmitted Disease Diabetes Adult onset ADD Ulcers Drug or food allergies and reaction: Medication List Please include prescription medication name, your dosage, and prescribing doctor. Include all over-thecounter medications, herbs, and vitamins Immunization History: (Write in date of most recent Bring immunization record) Tetanus: Hepatitis B: Hepatitis A: MMR: Pneumovax: Chicken Pox: Shingles:

16 Name: Date of birth: Date: Parents History: Both Healthy? Yes No Father Illnesses Cause of Death Age at Death Mother Illnesses Cause of Death Age at Death Siblings History: Number: All Healthy? Yes No 1 Brother / Sister / Half Illnesses Cause of Death Age at Death 2 Brother / Sister / Half Illnesses Cause of Death Age at Death 3 Brother / Sister / Half Illnesses Cause of Death Age at Death 4 Brother / Sister / Half Illnesses Cause of Death Age at Death 5 Brother / Sister / Half Illnesses Cause of Death Age at Death 6 Brother / Sister / Half Illnesses Cause of Death Age at Death 7 Brother / Sister / Half Illnesses Cause of Death Age at Death 8 Brother / Sister / Half Illnesses Cause of Death Age at Death Children(s) History: Number: All Healthy? Yes No 1 Son / Daughter Illnesses Cause of Death Age at Death 2 Son / Daughter Illnesses Cause of Death Age at Death 3 Son / Daughter Illnesses Cause of Death Age at Death 4 Son / Daughter Illnesses Cause of Death Age at Death 5 Son / Daughter Illnesses Cause of Death Age at Death 6 Son / Daughter Illnesses Cause of Death Age at Death

17 Name: Date of birth: Date: Social History: Illicit Drug Use: NO YES Type: Year Quit: Alcohol Use: None Minimal Moderate Large Recovering Alcoholic TYPE: Beer Wine Hard Liquor Tobacco Use: Did you ever use tobacco products? YES NO Cigarettes Pipe Cigar Smokeless Tobacco Max Amt Total years smoking Year Quit Caffeine Use: None Minimal Moderate Large Exercise: NO YES Type: Frequency: Occupation: Currently Working Yes No Birth Control Method: Women Only: Number of Pregnancies: # of Deliveries Hysterectomy: Age Method: Vaginal or Abdominal Ovaries removed: YES NO Last Pap Smear: Last Mammogram: Last Dexa Scan: Surgical History: (please circle all that apply) Appendix Carpel Tunnel Release Hip Replacement Thyroid Surgery Back Surgery Cataract Surgery Hysterectomy Tubal Ligation Breast Augmentation Gallbladder Knee Arthroscopy Vasectomy Breast Biopsy Colectomy Knee Replacement Wisdom Teeth Breast Reduction D&C of Uterus Mastectomy R or L Prostate Biopsy C-Section LEEP Kidney Surgery Prostatectomy-Total Coronary Bypass Surgery Hemorrhoid Surgery Spleen Removal PTCA Carotid Surgery Hernia Repair Tonsil and Adenoids Other: Date of last: Colonoscopy EGD Stress test Pharmacy Information: Name of Local Pharmacy City: Phone number Name of Mail order Pharmacy Phone number

18 North Country Family Practice, P.A. Patient Consent and Acknowledgement of Receipt of Privacy Notice I understand that as part of the provision of healthcare services, North Country Family Practice, P.A. creates and maintains health records and other information describing, among other things, my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I have been provided with a Notice of Privacy Practices that provides a more complete description of the uses and disclosures of certain health information. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their Notice and practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations (quality assessment and improvement activities, underwriting, premium rating, conducting or arranging for medical review, legal services, and auditing functions, etc.) and that the organization is not required to agree to the restrictions requested. By signing this form, I consent to the use and disclosure of protected health information about me for the purposes of treatment, payment and health care operations. I have the right to revoke this consent, in writing, except where disclosures have already made in reliance on my prior consent. This consent is given freely with the understanding that: 1. Any and all records, whether written or oral or in electronic format, are confidential and cannot be disclosed for reasons outside of treatment, payment or health care operations without my prior written authorization, except as otherwise provided by law. 2. A photocopy or fax of this consent is as valid as this original. 3. I have the right to request that the use of my Protected Health Information, which is used or disclosed for the purposes of treatment, payment or health care operations, be restricted. I also understand that the Practice and I must agree to any restriction in writing that I request on the use and disclosure of my Protected Health Information; and agree to terminate any restrictions in writing on the use and disclosure of my Protected Health Information which have been previously agreed upon. Patient s name printed Date Patient s signature (or guardian, if a minor) Social Security Number (for identification purposes) Witness (optional) Date Revised: May 22, 2006

19 North Country Family Practice 1050 E. Hwy 114, Suite 100, Southlake, Texas / fax 817/ AUTHORIZATION TO RELEASE MEDICAL RECORDS I, hereby authorize INFO OF OFFICE THAT WILL BE RELEASING YOUR RECORDS Name: Address: City, St., Zip: Office Telephone: Fax: To disclose the following specific medical information by mail or fax TO: NORTH COUNTRY FAMILY PRACTICE 1050 E. Hwy 114, Suite 100, Southlake, Texas * fax 817/ From the Health Records of: PATIENT S INFORMATION Name: DOB Last 4 of SS# Address: City, St., Zip: For the purpose of: My authorization extends only to those data elements/documents initialed below: Statements of charges or payments Records of visits (all visits) Progress Notes Photographs, videotapes, digital or other images Discharge summary History and Physical Examination Consultation Reports Record of visit for specific date or dates specific dates include or are limited to: Copies of records or reports provided to the above named (i.e.hospital, lab, clinic, etc) All of the above Other (Must be specific) Mental Health and/or alcohol and drug abuse treatment Hepatitis information This authorization is given freely with the understanding that: 1. Any and all records, whether written or oral or in electronic format, are confidential and cannot be disclosed without my prior written authorization, except as otherwise provided by law. 2. A photocopy or fax of this authorization is as valid as this original. 3. I may revoke this authorization at any time, except where information has already been released. This authorization is valid for a one year period from the date it is signed, or sooner if noted below. The revocation must be in writing. A revocation form is available from the receptionist. 4. North Country Family Practice, P.A., its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. 5. Treatment, payment, enrollment or eligibility for benefits may not be conditioned upon obtaining this Authorization. 6. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and is no longer protected. Patient s Name Printed Patient s signature (or guardian, if a minor) Social Security Number (for identification purposes only) Patient s Personal Representative Date Expiration date (if other than one year from date above) Date of Birth Date Patient s Personal Representative s Authorization to Act Witness