Patient Information Sheet

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Donald Clarke
6 years ago
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3 Patient Information Sheet Lat Name: Firt Name: Middle Initial: Maiden Name: Preferred Name: SSN : DOB: Driver' Licene #: Sex: Marital Statu: Street Addre: Preferred Provider: Home #: Work #: City, ST Zip: Cell #: Do you have an addre: Ye No *By providing your addre you will have acce to our patient portal. Through the patient portal you will have acce to your health hitory, you can ak u quetion, requet refill, or requet appointment. Race (Circle One): Ethnicity (Circle One): American Indian/Alaka Native Nat Hawaiian/Pacific Ilander Hipanic/Latino Declined Aian White Black/African American Other Race Not Hipanic/Latino Unknown Decline Unknown Preferred Communication Primary Language Ued (Circle One) (Circle One) Patient Portal Arabic Englih French Greek Italian Korean Portugee Spanih Mail Fax Phone Text Chinee Filipino German Hindi Japanee Polih Ruian Vietnamee Preferred Pharmacy: Family Phyician: Name: Addre: City, State Zip: Referring Phyician: Employer: Emergency Contact: Phone # Primary In: Policy ID #: Policy Holder: Group #: Policy Holder Relationhip: Policy Holder D.O.B.: Policy Holder S.S.#: Secondary In: Policy ID #: Policy Holder: Group # Policy Holder Relationhip: Policy Holder D.O.B.: Policy Holder S.S.#: Reponible Party: Social Security # Addre: Date of Birth: City, ST, Zip: EVERYTHING ABOVE IS CORRECT TO THE BEST OF MY KNOWLEDGE Authorization and Acknowledgement I / We hereby tate that the above information i true and correct to the bet of my / our knowledge. I / We authorize the above named practice to releae any information acquired in the coure of my treatment to my inurance company, employer, Phyician, intitution or third party payor, a required for certain claim filed. Furthermore, I / We authorize any medical treatment, anethetic, or urgical procedure deemed neceary by phyician. Initial: I / We authorize releae of any medical information neceary to proce inurance claim and authorize direct payment to be made to the above named practice for any and all medical or urgical ervice rendered, including any and all right to penaltie and / or court cot, attorney' fee or collection agency fee up to 50% of the amount owed under Louiiana Law, including LA R.S. 22:657. If I am a participant in a managed care plan, I alo authorize the audit of my chart by the plan. I / We undertand if any ervice are not covered by inurance or my eligibility cannot be verified, I am reponible for charge incurred. Initial: I / We acknowledge that I have either received and / or wa offered a copy of the office' Notice of Privacy Practice, which explain how my medical information will be ued and / or dicloed. I / We acknowledge receipt and / or offering of a copy of Southern ENT' current office policie and dicloure of financial interet. Signature of Patient / Parent/ Guardian Printed Name Date

5 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMAITON ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMAITON. PLEASE READ IT CAREFULLY. The Health Inurance Portability & Accountability Act of 1986 ( HIPPA ) i a Federal program that requet that all medical record and other individually identifiable health information ued or dicloed by u in any form, whether electronically, on paper, or orally are kept properly confidential. Thi Act give you, the patient, the right to undertand and control how your peronal health information ( PH ) i ued. HIPPA provide penaltie for covered entitie that miue peronal health information. A required by HIPPA, we prepared thi explanation of how we are to maintain the privacy of your health information and how we may dicloe your peronal information. We may ue and dicloe your medical record only for each of the following purpoe: treatment, payment and health care operation. Treatment mean providing, coordinating, or managing health care and related ervice by one or more healthcare provider. An example of thi would include referring you to a retina pecialit. Payment mean uch activitie a obtaining reimburement for ervice, confirming coverage, billing or collection activitie, and utilization review. An example of thi would include ending your inurance company a bill for your viit and/or verifying coverage prior to a urgery, Health Care Operation include buine apect of running our practice, uch a conducting quality aement and improving activitie, auditing function, cot management analyi, and cutomer ervice. An example of thi would be new patient urvey card. The practice may alo dicloe your PHI for law enforcement and other legitimate reaon although we hall do our bet to aure it continued confidentiality to the extent poible. We may alo create and ditribute de-identified health information by removing all reference to individually identifiable information. We may contact you, by phone or in writing, to provide appointment reminder or information about treatment alternative or other health-related benefit and ervice, in addition to other fundraiing communication, that may be of interet to you. You do have the right to opt out with repect to receiving fundraiing communication from u. The following ue and dicloure of PHI will only be made puruant to u receiving a written authorization from you: Mot ue and dicloure of pychotherapy note; Ue and dicloure of your PHI for marketing purpoe, including ubidized treatment and health care operation; Dicloure that contitute a ale of PHI under HIPPA; and Other ue and dicloure not decribed in thi notice. You May revoke uch authorization in writing and we are required to honor and abide by that written requet, except to the extent that we have already taken action relying on your authorization. You may have the following right with repect to your PHI, The right to requet retriction on certain ue and dicloure of PHI, including thoe related to dicloure of family member, other relative, cloe peronal friend, or any other peron identified by you. We are, however, not required to honor a requet retriction except in limited circumtance which we hall explain if you ak. If we do agree to the retriction, we mut abide by it unle you agree in writing to remove it. The right to reaonable requet to receive confidential communication of Protected Health Information by alternative mean or at alternative location. The right to inpect and copy your PHI. The right to amend your PHI. The right to receive an accounting of dicloure of your PHI. The right to obtain a paper copy of thi notice from u upon requet. The right to be advied if you re unprotected PHI i intentionally or unintentionally dicloed. If you have paid for ervice out of pocket, in full, and you requet that we not dicloe PHI related olely to thoe ervice to a health plan, we will accommodate your requet, except where we are required by law to make a dicloure. We are required by law to maintain the privacy of your Protected Health Information and to provide you the notice of our legal dutie and our privacy practice with repect to PHI. Thi notice i effective a of September 26, 2013 and it i our intention to abide by the term of the Notice of Privacy Practice and HIPPA Regulation currently in effect. We reerve the right to change the term of our Notice of Privacy Practice and to make the new notice proviion effective for all PHI that we maintain. We will pot and you may requet a written copy of the revied Notice of Privacy Practice from your office. You have recoure if you feel that your protection have been violated by our office. You have the right to file a formal, written complaint with the office and with the Department of Health and human Service, Office of Civil Right. We will not retaliate againt you for filing a complaint. Feel free to contact the Practice Compliance Officer for more information, in peron or in writing.

PATIENT INFORMATION Please Print

PATIENT INFORMATION Please Print DATE Patient s Last Name First Name Middle Name Suffix Gender: q Male q Female Social Security Number of Birth Race Ethnic Group: q Hispanic q Non-Hispanic q Unknown Preferred