Karen Lopez - Bartlett, FNP-C 2400 Augusta Suite 210 Houston, Texas 77057 Phone: 832.970.0228 Fax: 713.278-7885 Welcome! We are honored that you have chosen us to help in your search for optimum health. This is your New Patient Information Packet. Please read, fill out and sign the attached forms and bring them with your to your appointment unless you have been instructed to send them in prior to your appointment. In addition, we request that you also bring the following: 1. We accept cash and personal checks. 2. Driver s License or other official photo I.D. 3. ALL MEDICATIONS AND VITAMINS/SUPPLEMENTS YOU ARE CURRENTLY TAKING. If you wish to cancel or reschedule your appointment, please notify our office 24 hours or more prior to your scheduled appointment. We charge a fee of $200 for missed appointments if less than 24 hours cancellation notice is given. If you have any questions please call our office at (832) 970-0228. We look forward to meeting you! Many of our patients are sensitive to environmental substances, therefore we ask all patients to refrain from wearing scented hairsprays, colognes, perfumes, aftershaves, etc. on the days you are here. I understand that I am seeking alternative and integrative healthcare for optimal wellness. We do not treat disease, rather we help establish the body's own natural healing capabilities through natural remedies, such as oxidative therapies, detoxification, IV nutrition and bio-identical hormone therapies. With this understanding, I will keep my licensed physician informed. Any attached medical material is intended to inform and educate. No specific claims are intended or can be implied by such information. Information on some therapies may contain statements of unproven scientific validity and may not be of general acceptance. There is no claim being made as to the superiority of these methods over any other. Karen Lopez-Bartlett, FNP provides this information as part of informed consent. Patient Signature: Date:
Financial Policy We are here to help you take care of your health in the best way that we know how. We realize you came in about health and not finances. The following is to assist you in understanding the financial policies. WE ACCEPT CASH, AND PERSONAL CHECKS 1. MEDICAL RECORDS will be shared with another physician at your written request at no charge to you. If you require a copy of your chart, you will be charged $50 for this service. 2. MISSED APPOINTMENTS: If you are unable to make your appointment, we must have notice from you 24 hours in advance. If less than 24 hours notice is given, there will be a missed appointment fee of $200. 3. RETURNED CHECKS will incur a $50 fee. The amount of the check plus the fee must be paid within 10 days of notification by money order or cash to prevent further action. If a second check is returned on your account, we will no longer be able to accept personal checks as payment. 4. PRODUCTS will not be given without payment. Pre-payment by Visa and MasterCard to include the shipping and handling is required. 5. PRODUCTS are not returnable. All purchases are final. 6. I understand that any diagnostic testing that is recommended and performed are my sole responsibility. If private health insurance does not cover costs, Karen Lopez-Bartlett, FNP, is not to be held responsible. *I understand that I will have asked Karen Lopez - Bartlett, FNP for help and that he/she will help to the best of her ability. *By my signature below, I attest that I have read the above financial policy of Karen Lopez-Bartlett, FNP and that I understand that I am responsible for any charges not paid by my insurance carrier, as well as all charges, as appropriate, described above. Patient s name printed Patient s signature Date
Personal Information Name Gender M / F Referred By Address City State Zipcode Phone (home) (work) (cell) Email address Marital Status SS# Date of Birth Drivers License (state and number) Employer Name Pharmacy Name Location Phone # Emergency Contact: Name Phone # Cell No. Relation to Patient Patient s Signature Date
Disclosure And Consent For: (Patient Printed Name) To the patient: You have the right as a patient, to be informed about your condition and how integrative and complementary medicine may be applied in a treatment. This disclosure is intended to provide an opportunity for you to make an informed decision so that you may give or withhold your consent to treatment that may be considered unconventional by physicians trained only in the United States. Notice: Refusal to consent to the integrative and complementary procedure(s) shall not affect your right to future care or treatment. As of (date), I voluntarily have requested the following health care personal Karen Lopez-Bartlett F.N.P. and staff to treat me (or the person for whom I am responsible) as they deem necessary, as explained below: I understand, that when possible, laboratory exams will be filed utilizing my health insurance. If the insurance company does not submit payment for laboratory exams, I understand that I will be responsible for the balance. (initial) I understand that the following integrative and complementary treatment(s) is planned for me, (or the person for whom I am responsible) and I voluntarily consent and authorize the following: Administration of Homeopathic Remedies, Herbal and Nutritional Supplementation, IV Nutritional Therapies, Detoxifying Procedures, off-label use of pharmaceuticals, non-narcotic pain management to include oxidation therapies. I understand that no warranty or guarantee has been made regarding results of treatment. I realize that there may be risks and hazards in treating this present health condition with or without conventional medicine and there may also be risks and hazards related to the planned integrative and complementary treatment. I have been given an opportunity to discuss the possible risk and hazards of treatment and no treatment, and I believe that I have sufficient information to give this informed consent. I certify this form has been fully explained to me, that I have read it or have read to me, that the blank spaces have been filled in, and that I understand its contents. Agreement: I hereby authorize treatment to be rendered by Karen Bartlett, F.N.P. and staff. Patient / Legally responsible person sign here (signature required) Signed Printed Date Time AM/PM Witness Signature Witness Name (Please print)
Designation of Personal Representative As required by the Health Insurance Portability Act of 1996, you have the right to nominate one or more persons to act on your behalf with respect to the protection of health information that pertains to you. By completing this form you are informing us of your wish to designate the named person as your personal representative. You may revoke this designation at any time by signing and dating the revocation section of this form. Designation Section I, (print patient s name) hereby nominate the following person to act as my personal representative with respect to decisions involving the use and or disclosure of health information that pertains to me. Print Name of Personal Representative Date of Birth This person is to be afforded all of the privileges that would be afforded to me with respect to my health information unless restricted specifically below. Signature Date Revocation Section I hereby revoke this designation of a personal representative. Signature Date
Case History List the main problems that you are having, or reason for this appointment: Please attach additional page if necessary Past Medical History: Major Illnesses: Accidents or major trauma (Scars Please give location) Hospitalizations/Surgeries please give month/year if possible: Dental Procedures (root canals, etc.) Current Prescription Medications (names and doses):
Allergies and Sensitivities: Foods, environmental, etc. Ever tested? Copies of reports? Do you sweat? Occupational Exposures: Vaccinations: ( ) DPT (Diphtheria, Pertussis, Tetanus) Year(s) ( ) Booster (Usually DT) Year(s) ( ) Polio injection ( ) Polio oral Year(s) ( ) MMR (Measles, Mumps, Rubella Year(s) ( ) HBV (Hepatitis B Vaccine) Year(s) ( ) Other (Flu, Pneumovax, Shingles, etc.) Year(s) Lifestyle factors (Please fill in the approximate amounts): Never Occasionally Weekly Daily Coffee If yes, how much Tobacco If yes, how many a day Years Alcohol If yes, how many drinks a day Years Exercise Activities Never Minutes Hours Weekly Daily Women: Marital history: Years married # of children Ages No. of Pregnancies Deliveries complications Last Pap First day of last menstrual period Last Mammogram Last Colonoscopy(if over 50) Last Bone Density Test Last Cholesterol Screening Men: Erectile Dysfunction If yes, how many years Last Cholesterol Screening Last Colonscopy(if over 50) Prostate Screening PSA Digital Rectal Exam
Supplements IN ORDER TO HELP FACILITATE THE VISIT BETWEEN YOU AND YOUR PHYSICIAN, PLEASE FILL IN THIS FORM WITH ANY VITAMIN, MINERAL, AMINO ACID, OTHER SUPPLEMENTS OR MEDICATION THAT YOU MAY BE TAKING. NAME: DATE: SUPPLEMENTS MANUFACTURER FORM DOSAGE FREQUENCY Bronson Tablet 500 MG 2 per day EXAMPLE: Vitamin C COMMENTS:
Diet Log Please write down what you eat and drink for a week! This includes juice, coffee, alcohol. If you re attempting to follow any particular diet, please indicate that in the space below the table. (i.e. Swank diet, Atkins) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Breakfast Snack Lunch Snack Dinner Snack COMMENTS:
Family Medical History Please give age, lists of any illness, or if deceased. If deceased, list cause of death and age of death. Mother: Father: Brothers and Sisters: Possible Illnesses In Alphabetical Order: Allergies Asthma Bleeding Tendency Cancer, Type Chrons Disease Diabetes-Age at Onset Drug Abuse Epilepsy Gall Bladder Glaucoma Heart Disease-Type Hearing Loss High Blood Pressure Hypoglycemia Kidney Disease Liver Disease-Type Lupus Mental Illness- Type Multiple Sclerosis Rheumatoid Arthritis Thyroid Disease Tuberculosis Skin Disease-Type Other Conditions Mother s Parents: Father s Parents: Children:
Acknowledgement Of Receipt Of Notice Of Privacy Practices (You may refuse to sign this acknowledgement) By my signature below, I acknowledge that I have received a copy of this office s Notice of Privacy Practices (next page). Patient Name Printed Patient Signature Date For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (please specify):
Notice of Privacy Practices THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request. You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us directly. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment for you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities. Your Authorization: in addition to our use of your health information for treatment, payment, or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this notice. To your family and friends: We must disclose your health information to you, as described in the Patient Rights section of this notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Persons involved in care: We may use or disclose your health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Marketing health-related services: We will not use your health information for marketing communications without your written authorization. Required by law: We may use or disclose your health information when we are required to do so by law. Abuse or neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances. Appointment reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing to obtain access to your health information. We will charge you a fee for expenses such as copies and staff time. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means, you may complain to us. You may also submit a written complaint to the U.S. Department of Health and Human Services. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.