SOUTHWEST GASTROENTEROLOGY, P.A.
Responsible Party/Guarantor If other than above
If "No Insurance" is selected, please input "NA" on "Primary Insurance" and "Policy #" textboxes.
Emergency Contact
I, the undersigned, attest that the above information is true and complete, to the best of my ability:
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Telemedicine involves the real-time evaluation, diagnosis, consultation on, and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video, or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real-time.
I understand there are potential risks with this technology:
The benefits of a telemedicine consultation are:
Consent for Treatment. I hereby authorize to be interviewed by the physician and/or assistants to participate in my medical care through the use of telemedicine. I also understand other individuals may be present to operate the video equipment and that they will take reasonable steps to maintain confidentiality of the information obtained.
I acknowledge that the physician’s advice, recommendations, and/or decisions may be based on factors not within their control, such as incomplete or inaccurate data provided by me or distortions of images that may result from electronic transmission.
I hereby release Southwest Gastroenterology and its personnel and any other person participating in my care from any and all liability which may arise from the taking and authorized use of such videotapes, digital recording films and photographs.
I have read this document and understand the risk and benefits of telemedicine consultation and I hereby consent to participate in the telemedicine visit under the conditions described above.
Requirements:
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Bring medication list or list all medications currently taking including over-the-counter medications and prescription medications, and how much of each.
Effective Date: April 14, 2003
If you have any questions about this notice, please contact:
Privacy Officer:
Melanie Tsen
911 S. Hwy 123 Bypass
Seguin, Texas 78155
(830) 372-9042
This Notice tells how this Practice, its physician(s), or other health care professionals who work under contract or under the direction of our Practice and our staff, may use and disclose medical information about you. Other personnel affiliated with our practice who are authorized to have access to your medical records, are subject to this notice. In addition, this Practice, in cooperation with other healthcare facilities, providers and/or insurance carriers may share medical information with each other for treatment, payment, or health care operations described in this notice. This Notice also describes your rights and our obligations regarding the use and disclosure of this information. Additionally, this Notice applies to all your records created and/or maintained by this Practice.
We understand that medical information about you and your health is personal. We are committed to protecting this information. Each time you visit our Practice, a record of the care and services you receive is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, plan for future care or treatment, and billing record. This record serves as a:
This Practice shall:
Listed below are different ways we may use and disclose your medical information. Examples serve only as illustrations and do not include every possible use or disclosure.
We will use and disclose your protected health information to provide, coordinate, or manage your health care services. For example, we may share your information with other specialists to whom you are referred for treatment.
We will use and disclose medical information about you so that you, your insurance company, or a third party may be billed for services. For example, we may need to disclose protected health information to a health plan (insurer) in order for your health plan to pay us for the services rendered to you. We may also tell your health plan about a treatment or procedure you are going to receive in order to obtain prior approval and to determine whether your plan will cover the expenses for the procedure
We may use and disclose medical information about you for office operations. These uses and disclosures are necessary to run this Practice in an efficient manner and ensure that all patients receive quality care. For example, your medical records and health information may be used in the evaluation of health care services to determine appropriateness and quality of health care treatment. In addition, medical records are audited for documentation and billing purposes
We may use and disclose medical information in order to remind you of an appointment. For example the Practice may send you a written notice or telephone reminder that your next appointment is coming up.
We will disclose medical information about you when required to do so by federal or Texas laws or regulations.
Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of patients who received one medication to those who received another medication for the same condition. All research projects are subject to a special approval process. We will ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are.
We may use and disclose medical information about you to medical or law enforcement personnel to prevent a serious threat to your health and safety or the health and safety of the public or another person.
This Practice does not share patient's health information with outside firms for product marketing. We may use certain information (name, address, telephone number, dates of service, age, and gender) to send you information about the Practice's health programs, services, and growth. If you do not wish to receive this information, please write to the Practice Manager whose address is listed on the front page of this notice.
If you have indicated in writing your desire to be an organ donor, we may release medical information to organizations that handle procurement of organs, eyes, or tissue transplantations.
If you are or were a member of the armed forces, we may release medical information about you as required by military or other authorities.
We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
We may disclose medical information for management audit, financial audit, or program evaluation. The personnel involved in these operations may not identify you in any report, audit, or evaluation, or otherwise disclose your identify in any way
We may release medical information if asked by a law enforcement official or required by a court order or subpoena. We may release information if we determine that there is a probability of imminent physical injury to you or to another person, or immediate mental or emotional injury to you. [This paragraph may not apply to very specific patients who are Practice Patients under particular and specific circumstances.]
We may use and disclose medical information about you to another physician or healthcare facility in the sale, transfer, merger, or consolidation of this physician's practice.
We may disclose medical information about you for public health activities. These activities generally include the following:
To notify the appropriate governmental authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. All such disclosures will be made in accordance with the requirements of Texas and federal laws and regulations
We may disclose medical information to a health oversight agency for specific activities. Health oversight agencies are authorized by law to oversee the health care system. For example, an oversight agency may perform audits, investigations, inspections, and evaluations for licensure. These activities are necessary for the government to monitor government programs, eligibility or compliance, and to enforce health-related civil rights and criminal laws
If you are involved in a lawsuit or in administrative disputes, we may disclose medical information about you in response to court or administrative orders
We may release medical information to a coroner or medical examiner when authorized by law (e.g., to identify a deceased person or determine the cause of death). We may also release medical information about patients to funeral directors.
If you are an inmate of a correctional facility, we may release medical information about you to the correctional facility so that the facility can provide you with treatment.
You have the following rights concerning your medical information.
You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes medical and billing records, but does not include psychotherapy notes. You must submit a request in writing to the Practice Manager and/or this office's Privacy Officer if you wish to inspect and copy medical information that may be used to make decisions about you. If you request a copy of the information, this Practice may charge you a fee for copying, mailing, or summarizing your medical records. You must submit a written request if you wish to view your psychotherapy notes.
We may deny your request to inspect and copy your records because of special circumstances. If you are denied access to medical information including psychotherapy notes, you may request that we review our denial. Another licensed health care professional chosen by this Practice will review your request and our denial. The person conducting the review will not be the person who denied your initial request. This Practice will comply with the outcome of the review.
If you feel that medical information maintained about you is incorrect or incomplete, you may ask the Practice to amend the information. You have the right to request an amendment of your information for as long as the information is kept by the Practice.
To request an amendment, your request must be made in writing and submitted to the Practice Manager and/or Privacy Officer of this Practice. In addition, you must provide a reason to support your request.
We may deny your request to amend your medical records if your request is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
You have the right to request an accounting of disclosures of your medical information made by the Practice for purposes other than treatment, payment, or health care operations.
To request this accounting, you must submit your request in writing to the Practice Manager and/or Privacy Officer of this Practice. Your request must state how long a period of time you wish the accounting to cover. The accounting cannot exceed a period of six (6) years beginning April 14, 2003. Your request should indicate in what format you want the accounting (paper or electronically). The first accounting you request within a 12-month period will be free. You may be charged for additional accountings within the same 12-month period. We will notify you of the cost so that you may choose to withdraw or modify your request if costs seem excessive.
You have the right to request a restriction or limitation on the medical information the Practice uses or discloses for your treatment, payment or health care. You also have the right to request a limit on the medical information the Practice discloses about you to someone outside the Practice for care or payment. This Practice is not required to agree to your request. Should this Practice agree to your request, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to the Practice Manager and/or Privacy Officer of this Practice. In your request, you must indicate:
You have the right to request that this Practice communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that this Practice contact you only at work or by mail.
If you want to request that we communicate with you in a certain manner, you must make your request in writing to the Practice Manager and/or Privacy Officer of this Practice. You do not have to state a reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish the communication to be directed.
If you wish your bill sent to another address, or if you have questions regarding your bill and the Practice's billing procedures, you may direct you questions and concerns to this Practice's Office Manager.
We reserve the right to change our practices and to make new provisions effective for all the protected health information we maintain. Should our information practices change, we will post the amended NOTICE OF PRIVACY PRACTICES in the office waiting area and on our website (if applicable). You may request that a copy be provided to you by contacting the Practice Manager and/or Privacy Officer of this Practice.
If you believe your privacy rights have been violated, you may file a complaint with the Practice Manager and/or Privacy Officer of this Practice or with the Office for Civil Rights, U.S. Department of Health and Human Services.
To file a complaint with this Practice, contact: Privacy Officer: Melanie Tsen (830) 372-9042
All complaints to the Office for Civil Rights should be submitted in writing.
The address for the Office of Civil Rights is:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, D.C. 20201
Your complaint must be filed within 180 days of when you knew or should have known that the act occurred.
You will NOT be penalized for filing a complaint.
I acknowledge that this Practice has provided me with a written copy of the Notice of Privacy Practices.
I understand that as provided in the Notice of Privacy Practices, the terms of the Notice may change. If they do, I may obtain a revised copy from the Privacy Officer by calling 830-372-9042.
I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.
I understand that I may revoke this consent in writing, except to the extent that Physician has already taken action in reliance thereon. I also understand that by refusing to sign or revoking this consent, Physician may refuse to treat me. I wish to restrict the use or disclosure of my health information as follows:
Please list who you want to release information to:
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
PHYSICIAN INFORMATION
Name: Southwest Gastroenterology, P.A.
Address: 911 S State Hwy 123 Bypass Seguin, Tx 78155
Email: Info@swgastroenterology.net
Risks of using email
The physician offers patients the opportunity to communicate by email. Transmitting patient information poses several risks of which the patient should be aware. The patient should not agree to communicate with the physician via email without understanding and accepting these risks. The risks include, but are not limited to, the following:
The patient:
Conditions of using email
The physician will use reasonable means to protect the security and confidentiality of email information sent and received. However, because of the risks outlined above, the physician cannot guarantee the security and confidentiality of email communication. Thus, patients must consent to the use of email for patient information. Consent to the use of email includes agreement with the following conditions:
The patient can add to or modify this list at any time by notifying the physician in writing.
Instructions for communications by email
To communicate by email, the patient shall:
Patient acknowledgement and agreement
I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of email between the physician and me, and consent to the conditions outlined herein, as well as any other instructions that the physician may impose to communicate with patients by email. I acknowledge the physicians right to, upon the provision of written notice, withdraw the option of communicating through email. Any questions I may have had were answered .
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.