New Patient Consent Form

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HIPAA Information and Consent Form

The 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 US Department of Health and Human Services www.hhs.gov.

We have adopted the following policies:

1. Patient 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.

2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, 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.

3. 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.

4. 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.

5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manger or the doctor.

6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.

7. We agree to provide patients with access to their records in accordance with state and federal laws.

8. We may change, add, delete, or modify any of these provisions to better serve the needs of the both the practice and the patient.

9. 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.

Consent to Obtain Patient Medication History

Patient medication history is a list of prescriptions that healthcare providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history.

The collected information is stored in the practice electronic medical record system and becomes part of your personal medical record. Medication history is very important in helping providers treat your symptoms and/or illness properly and avoid potentially dangerous drug interactions.

It is very important that you and your provider discuss all your medications in order to ensure that your recorded medication history is 100% accurate. Some pharmacies do not make prescription history information available, and your medication history might not include drugs purchased without using your health insurance.

Also, over-the-counter drugs, supplements, or herbal remedies that you take on your own may not be included.

I hereby give my permission to Evolve Healthcare or any of their affiliated physicians, as my healthcare provider to obtain my medication history from my pharmacy, health plan(s), and my other healthcare providers.

Consent to Treatment

I hereby give my permission for Evolve Healthcare or any of their affiliated physicians to give me medical treatment.

I hereby give my permission for Evolve Healthcare or any of their affiliated physicians to file for insurance benefits to pay for the care I receive.

I understand:

• That Evolve Healthcare will have to send my medical record information to my insurance company
• I must pay my share of the costs.
• I must pay for the cost of these services if my insurance does not pay, or I do not have insurance.
• I have the right to refuse any procedure or treatment.
• I have the right to discuss all medical treatments with my provider.

Lab Test Policy: Evolve Healthcare or any of their affiliated physicians may order labs that insurance may or may not cover, depending on individual plans, but it is my responsibility to understand my insurance coverage, including lab testing fees.

Evolve Healthcare or any of their affiliated physicians is not responsible for any billing related to insurance claims. What you might owe for lab tests and what is covered by insurance varies widely from network to network. To prevent the stress of unexpected bills we urge you to contact your insurance company so you can have a good understanding of your lab benefits prior to completing any lab tests. We have no financial relationship with the lab companies, and we do not mark up or profit in any way from the sale of lab testing kits that we order for clients. Your relationship with

Consent to Disclose Patient Health Information to Authorized Individual(s)

I understand that Evolve Healthcare or any of their affiliated physicians will NOT disclose my protected health information to my family, friends or relatives unless specified below.

I understand that Evolve Healthcare or any of their affiliated physicians may disclose my protected health information to my family, friends, or relatives that I identify as an entity directly involved in my care, insurance information, and/or payment of my care. I understand that I have the opportunity to agree or object to such disclosure.

The individual(s) named below is/are directly involved in my care and I would like these individuals to give and receive information from my physician Evolve Healthcare regarding my medical condition and treatment. Therefore, I hereby consent, agree, and authorize Evolve Healthcare and my physician to disclose my protected health information to the following individual(s):

I understand that by consenting to the disclosure of my protected health information to the individual(s) named above, all my personal information relevant to my care and treatment may be disclosed including, but not limited to, my medical history, my medical condition, diagnostic test results, laboratory results, surgical procedures and other personal information given to, or discussed with, my physician at his medical office.

This consent is effective immediately and shall remain in effect until I revoke it. I understand that I have the right to revoke this consent at any time by providing written notice to Evolve Healthcare at the following address: 20301 Ventura Blvd. Ste 210 Woodland Hills, CA 91364. I further understand that I am NOT required to sign this form in order to receive treatment, and that I am voluntarily requesting and consenting to disclose my protected information to the individual(s) named above.’