Patient Information Form

Please correct the errors described below.

PATIENT'S RESPONSIBLE PARTY INFORMATION

PATIENT'S INSURANE INFORMATION

PATIENT'S REFERRAL INFORMATION

EMERGENCY CONTACT

EMPLOYEMENT

NEWBORN INFORMATION

HEALTH HISTORY QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

PERSONAL HEALTH HISTORY

SURGERIES

Add Additional Surgeries

OTHER HOSPITALIZATIONS

Add Additional Hospitalizations

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Add Additional Drugs

Allergies to medications

Add Additional Allergies to Medications

HEALTH HABITS AND PERSONAL SAFETY

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.

Exercise

Diet

# of meals you eat in an average day?

Alcohol

Tobacco

Drugs

Sex

If not trying for a pregnancy list contraceptive or barrier method used:

Personal Safety

Family Health History

Add Additional Family Member

Mental Health

Women Only

Men Only

Other Problems

HIPAA PRIVACY NOTIFICATION FORM

If we are unable to reach by at your home phone we will try one of the checked boxes below. If we are unsuccessful, we will then mail you a letter as a final attempt to inform your of results.

It is often difficult to reach patients and our staff may not always be readily available when patients respond to call back message left on answering machines or with a family member. To facilitate contacting you in a timely manner and to comply with federal HIPAA regulations, please complete the following. Please check the appropriate choice or choices for you

Results regarding sexually transmitted diseases, whether positive or negative, will ONLY be given to the Patient.

I understand that Brenham Family Practice and Obstetrics will make reasonable for as long as I am a patient: but I can request a change at any time. I further situations, my protected health information may understand be released. efforts to accommodate this request that in some emergency.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Employment

Newborn Information

BRENHAM FAMILY PRACTICE AND OBSTETRICS HIPPA PRIVACY AND DISCLOSURE POLICY NOTICE

Privacy and Disclosure Authorization Policy: For Storage and Disclosure of Confidential Information and Records

1. This Notice describes how your health information, including therapy records, may and may not be used and disclosed to others, and how you may gain access to this health information. Please review the information in this Notice carefully.

2. The Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides strict guidelines about the maintenance, use, storage, and disclosure of client medical information called Protected Health Information (PHI). HIPAA also requires that those who receive health services be given written statements of the privacy policies of the health providers. In addition to HIPAA guidelines, there are many other federal, state, and professional guidelines and ethical standards that inform our policies and practices at BRENHAM FAMILY PRACTICE AND OBSTETRICS PA. While we are required to keep records of services provided, we are also required to safeguard this information. BRENHAM FAMILY PRACTICE AND OBSTETRICS PA staff will make every effort to safeguard your privacy and your rights.

3. You as a health services consumer have a right to know how information about you and about services you receive may be used. You also have rights to ask for limits on the disclosures made on your behalf, and to have appropriate access to your records for review and release.

4. The Policies and Practices of Health In Balance Physical Therapy, LLC. regarding PHI privacy and disclosure are contained in the Notice. The purposes for the maintaining and disclosing of client records relates to providing services, as requested by our clients, and generally are involved in treatment, payment, and other health care operations, such as those required by government agencies or in emergency situations.

5. Based on legal regulations and ethical guidelines, BRENHAM FAMILY PRACTICE AND OBSTETRICS PA will only disclose information about you to persons or organizations outside of our clinic in a limited number of situations:

  • With your written and specific permission (consent).
  • If required to do so by certain specific court orders, subpoenas, or Workers' Compensation inquires.
  • In cases where laws require reporting for protection, such as significant danger to self or others, child, or elder abuse or neglect.
  • When confidential audits are lawfully conducted by governmental or insurance oversight agencies (such as for clinic licensing).
  • When an emergency required immediate communication with appropriate persons in order to secure appropriate help or treatment: in these situations, the minimum disclosure necessary to secure services will be provided.
  • In order to bill for services provided by BRENHAM FAMILY PRACTICE AND OBSTETRICS PA. Payers are typically insurance companies or other responsible parties. Billing services and insurance companies are also bound by HIPAA and other governmental agencies.
  • When a client in treatment is transferred or completes treatment, follow-up contact is required by statute.
  • Note: when the client is a minor, privacy rights belong to the parents, except in certain situation. Please discuss age-related rights with your doctor.

6. Based on legal regulations and ethical guidelines, BRENHAM FAMILY PRACTICE AND OBSTETRICS PA doctors/nurses/staff will use or disclose your PHI within the clinic:

  • To provide services to you, including Consultation and coordination of services among personnel and professional consultants (as appropriate), in order to aid in the diagnosis, assessment and treatment planning, and in the facilitation of ongoing treatment, with professional supervision as required by law
  • To maintain business records, as required legally and ethically. We maintain client records in file folders, kept in locked file cabinets, and are destroyed by shredding after they have been held as required by law (and not less than seven years after client discharge). BRENHAM FAMILY PRACTICE AND OBSTETRICS PA also maintains records on the computer, respecting legal and ethical privacy guidelines.
  • To share and discuss with you your PHI as contained in clinic records, with a prior written request; also, you may update or correct (add to) your PHI as needed. State law does provide some restrictions on these rights (when judged to be in your best interest). In addition, you may request a listing of non-routine disclosures made of your PHI records. You may also choose how we communicate with you, as via an alternative address or phone number.
  • Examples of other situations that might involve disclosure: Consultation regarding emergency planning, defense of lawsuits, or processing of grievances, or you bring a friend with you during therapy sessions.

7. Consent: Your signature on your new patient demographics, indicates that you are aware of the collection and storage of treatment, payment, and other health care information and that you consent to its use in the course of services provision, billing, and collection procedures, and within BRENHAM FAMILY PRACTICE AND OBSTETRICS PA, as discussed above. This form has no expiration date unless amended or revoked. You may revoke this consent with written notice at any time, except to the extent that it has already been acted upon. You may restrict the released information and its use, as indicated on the appropriate form, or restrict its use within BRENHAM FAMILY PRACTICE AND OBSTETRICS PA, but doing so may legally or ethically compromise our ability to provide you with medical services. We may therefore determine that we are unable to provide those services in good faith.

8. There is a separate form for consent to release/exchange information with your insurance company or other third party payer.

9. Other relevant information: Fees for Copying Records: A uniform and reasonable fee may be charged for copying records, That fee may be reduced or waived in accordance with BRENHAM FAMILY PRACTICE AND OBSTETRICS PA policy. Health In Balance Physical Therapy, LLC will ordinarily have 2 weeks to respond to a request to copy records. Transportation of Records: Whenever records must be transported out of the office, great care will be taken to protect client privacy. Electronic Transmissions: E-mail and Internet communications may be used within BRENHAM FAMILY PRACTICE AND OBSTETRICS PA. In those rare instances, BRENHAM FAMILY PRACTICE AND OBSTETRICS PA staff will take care to limit identifying information within the messages and to make sure the recipient is authorized to receive the information. Future Changes: BRENHAM FAMILY PRACTICE AND OBSTETRICS PA will revise and update this information and form as needed, and in compliance with the law

Complaints: has BRENHAM FAMILY PRACTICE AND OBSTETRICS PA a Grievance Policy posted in the office: clients may ask any BRENHAM FAMILY PRACTICE AND OBSTETRICS PA staff for a copy of the policy. You may also contact any BRENHAM FAMILY PRACTICE AND OBSTETRICS PA for further information about our privacy and disclosure policies, or about HIPAA questions. Privacy concerns may be addressed to the Secretary of the U.S. Department of Health and Human Services. Information and assistance may be found through the HHS Office for Civil Rights (website:httc.www.hhs.gov/ocr/hipaa).

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information. Covered entities as that term are defined by HIPAA and Texas Health 8: Safety Code § 181 001 must obtain a signed authorization from the individual or the individuals legally authorized representative to electronically disclose that individual's protected health information. Authorization is not required for disclosures related to treatment, payment. health care operations, performing certain insurance functions, or as may be otherwise authorized by law, Covered entities may use this form or any other form that complies with HIPAA, The Texas Medical Privacy Act, and other applicable laws. Individuals cannot be denied treatment based on a failure to sign this authorization form, and a refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits.

I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL'S PROTECTED HEALTH INFORMATION

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?

Person/Organization Name:

BRENIIAM FAMILY PRACTICE AND OBSTETRICS

Address

601 MEDICAL PARKWAY, STE D, BRENHAM, TX, 77833

Phone & Fax

Phone: (979) 836-2822 Fax: (979) 836-l943

REASON FOR DISCLOSURE (Choose only one option below)

  • Treatment / Continuing Medical Care
  • Personal Use
  • Billing or Claims
  • Insurance
  • Legal Purposes
  • Disability Determination
  • School
  • Employment
  • Other

WHAT INFORMATION CAN BE DISCLOSED? Complete the following by indicating those items that you want disclosed. The signature of a minor patient is required for the release of some of these items If all health information is to be released, then check only the first box

Your initials are required to release the following information

EFFECTIVE TIME PERIOD: This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reaching the age of majority. or permission is withdrawn, or the following specific date (optional):

RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving ‘‘Written notice stating my intent to revoke this authorization to the person or organization named under "WHO CAN RECEIVE AND USE THE HEALTH INFORMATION." I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provided by Texas Health & Safety Code § 181.154(c) and/or 45 C.F.R. § 164.502(a)( I). I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

A minor individual's signature is required for the release of certain types of information, including, for example, the release of information related to certain types of reproductive care, sexually transmitted diseases, and drug, alcohol, or substance abuse, and mental health treatment (See. e.g., Tex. Fam. Code § 32.003).

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

IMPORTANT INFORMATION ABOUT THE AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

The Attorney General of Texas has adopted a standard Authorization to Disclose Protected Health Information in accordance with the Texas Health &Safety Code § 181.154(d). This form is intended for use in complying with the requirements of the Health Insurance Portability and Accountability Act and Privacy Standards (111PAA) and the Texas Medical Privacy Act (Texas Health & Safety Code, Chapter 181). Covered Entities may use this form or any other form that complies with HIPAA, the Texas Medical Privacy Act, and other applicable laws.

Covered entities, as that term is defined by HIPAA and Texas Health & Safety Code § 181.001, must obtain a signed authorization from the individual or the individual's legally authorized representative to electronically disclose that individual's protected health information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be otherwise authorized by law. (Tex. Health & Safety Code §§ 181.154(b),(c), § 241.153; 45 C.F.R. §§ 164.502(a)(1): 164.506. and 164.508).

The authorization provided by the use of the form means that the organization, entity, or person authorized can disclose, communicate. or send the named individual's protected health information to the organization, entity, or person identified on the form, including through the use of any electronic means.

Definitions - In the form, the terms "treatment," "healthcare operations," "psychotherapy notes," and "protected health information" are as defined in HIPAA (45 CFR 164.501). "Legally authorized representative" as used in the form includes any person authorized to act on behalf of another individual. (Tex. Occ. Code § 151.002(6); Tex. Health & Safety Code §§ 166.164, 241.151; and Tex. Probate Code § 3(aa)).

Health Information to be Released - If All Health Information- is selected for release, health information includes, but is not limited to, all records and other information regarding health history, treatment. hospitalization test, and outpatient care, and also educational records that may contain health information. As indicated on the form, specific authorization is required for the release of information about certain sensitive conditions. including

  • Mental health records (excluding "psychotherapy notes" as defined in HIPAA at 45 CFR 164.501).
  • Drugs, alcohol, or substance abuse records.
  • Records or tests relating to HIV/AIDS.
  • Genetic (inherited) diseases or tests (except as may be prohibited by 45 C.F.R. * 164.502).

Note on Release of Health Records - This form is not required for the permissible disclosure of an individual's protected health information to the individual or the individual's legally authorized representative. (45 C.F.R. § 164.502(a)(1)(i), 164.524: Tex. Health & Safety Code § 181.102). If requesting a copy of the individual's health records with this form, state and federal law allows such access unless such access is determined by the physician or mental health provider to be harmful to the individual's physical, mental or emotional health. (Tex. Health & Safety Code §§ 181.102. 611.0045(b); Tex. Occ. Code § 159.006(a); 45 C.F.R. § 164.502(a)(1)). If a healthcare provider is specified in the "Who Can Receive and Use The Health Information" section of this form, then permission to receive protected health information also includes physicians, other health care providers (such as nurses and medical staff) who are involved in the individual's medical care at that entity's facility or that person's office, and health care providers who are covering or on-call for the specified person or organization. and staff members or agents (such as business associates or qualified services organizations) who carry out activities and purposes permitted by law for that specified covered entity or person. If a covered entity other than a healthcare provider is specified, then permission to receive protected health information also includes that organization's staff or agents and subcontractors who carry out activities and purposes permitted by this form for that organization. Individuals may be entitled to restrict certain disclosures of protected health information related to services paid for in full by the individual (45 C.F.R. § 164.522(a)( I )(vi)).

Authorizations for Sale or Marketing Purposes - If this authorization is being made for sale or marketing purposes and the covered entity will receive direct or indirect remuneration from a third party in connection with the use or disclosure of the individual's information for marketing. the authorization must clearly indicate to the individual that such remuneration is involved. (Tex. Health & Safety Code §181.152, .153; 45 C.F.R. § 164.508 (a)(3). 14)).

Limitations of this form - This authorization form shall not be used for the disclosure of any health information as it relates to: (I) health benefits plan enrollment and/or related enrollment determinations (45 § 164.508(b)(00, .508(c)(2)(ii): (2) psychotherapy notes (45 C.F.R. § 164.508(b)(3 ii): or for research purposes (45 C.F.R. § 164.508(b)(3 )(i)

Use of this form does not exempt any entity from compliance with applicable federal or state laws or regulations regarding access, use, or disclosure of health information or other sensitive personal information (e.g., 42 CFR Part 2, restricting the use of the information pertaining to drug/alcohol abuse and treatment), and does not entitle an entity or its employees, agents or assigns to any limitation of liability for acts or omissions in connection with the access, use, or disclosure of health information obtained through use of the form.

Charges - Some covered entities may charge a retrieval/processing fee and for copies of medical records. Tex. Health & Safety Codes 241.154)

Right to Receive Copy - The individual and/or the individual's legally authorized representative has a right to receive a copy of this authorization.

Brenham Family Practice and Obstetrics Patient Portal Consent

Informed Consent to use Patient Portal

Brenham Family Practice and Obstetrics is offering this secure, HIPPA compliant communication tool as a courtesy to our patients and their parents. It is an optional service and we reserve the right to suspend or terminate it at any time. We will alert you to any changes as promptly as possible. This form is intended to inform you of the facts and risks surrounding the use of the web portal. By signing below, you confirm that you have read, understand, and agree to comply with our procedures and guidelines for using the Patient Portal. You also agree not to hold Brenham Family Practice and Obstetrics or any of their staff liable for network infractions beyond their control.

Privacy and Security

The web portal or webpage has a secure tunnel connection with our clinic that uses encryption to keep unauthorized persons from being able to access and read your health information or your communications to us. To help ensure that the tunnel remains secure, we need to have your current (private) email address and be informed if it ever changes. Keep your portal user ID and password secure so that only you, or someone authorized by you, can gain access to patient information. If you think someone has learned your password, immediately go to the portal site and change it.

Your email address is confidential and protected information. With our best effort, we will protect this information as we do your medical and personal information. We will never purposefully share this information with any third party. All-access to our internal network and electronic medical records (EMR) is password protected. Our staff is instructed to logoff their workstations when not physically present. Additionally, in compliance with HIPAA guidelines, our [MR automatically logs the user out after a period of inactivity. Similar to phone communications, messages may be read and addressed by different staff at Brenham Family Practice and Obstetrics. When your provider is ill or on vacation, your emails will be addressed by a covering provider. Please allow 48 hours for messages to be addressed. Messages left on Friday may not be addressed until Tuesday of the following week.

By signing below, I authorize Brenham Family Practice and Obstetrics to send communications through the patient portal and give my expressed consent for my medical information to be made available to my using www.healthportalsite.com/brenhamfamily. I understand that I have the right to receive a completed copy of this consent.

With patient portal you can: *view information anytime-anywhere *request refill for medication online *appointment reminders by email

Complete the following if the email address does not belong to patient:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Summary of Rights Under the Fair Credit Reporting Act

A free copy, of your Summary of Rights Under the Fair Credit Reporting Act, is available in our office upon request.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

MEDICAL APPOINTMENT CANCELLATION/NO SHOW POLICY

Thank you for trusting your medical care to Brenham Family Practice. When you schedule an appointment with Brenham Family Practice we set aside enough time to provide you with the highest quality care. Should you need to cancel or rescheduled an appointment please contact our office as soon as possible, and no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting for an appointment. Please see our Appointment Cancellation/No Show Policy below:

  • Any established patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours notice will be considered a No Show and charged a $50.00 fee.
  • Any established patient who fails to show or cancels/reschedules an appointment with no 24-hour notice a second time will be charged a $50.00 fee.
  • If a third No Show or cancellation/reschedule with no 24-hour notice should occur the patient may be dismissed from Brenham Family Practice.
  • Any new patient who fails to show for their initial visit may not be rescheduled.
  • The fee is charged to the patient, not the insurance company, and is due at the time of the patient's next office visit.
  • As a courtesy, when time allows, we make reminder calls for appointments. If you do not receive a reminder call or message, the above Policy will remain in effect.

We understand there may be times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances please contact our Office Manager, who may be able to waive the No Show fee. You may contact Brenham Family Practice at the numbers below. Should it be after regular business hours Monday through Friday, or a weekend, you may leave a message. Messages left at either location are acceptable.

Brenham Family Practice (979) 836-2822

I have read and understand the Medical Appointment Cancellation/No Show Policy and agree to its terms.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

FINANCIAL AGREEMENT

I understand my insurance is a contract between myself and my insurance company and that Brenham Family Practice and Obstetrics will bill my insurance as a courtesy to me. I understand that I am responsible for deductibles, co-pays, non-covered services, coinsurance, and items considered "not medically necessary" by my insurance company. I agree to pay copayments, deductibles, and/or coinsurance at the time of service. If a referral and/or preauthorization is required by my insurance company, I will assist Brenham Family Practice and Obstetrics in obtaining the referral and/or preauthorization. Brenham Family Practice and Obstetrics may verify benefits on my behalf; however, the final determination will be made by my insurance company at the time of payment. I understand that I am ultimately responsible for any balance on my account.

COLLECTION FEES AND RETURNED CHECKS

ASSIGNMENT OF BENEFITS

RELEASE OF INFORMATION

CONSENT FOR TREATMENT

NOTICE OF PRIVACY PRACTICES AND ACKNOWLEDGEMENT OF RECEIPT

I have read and agree to the Financial Agreement, Assignment of Benefits, Release of Information, and Consent For Treatment as listed above. My signature below also indicates that I have reviewed a copy of the Brenham Family Practice and Obstetrics Notice of Privacy Practices and I have indicated any restrictions on my protected health information above. Everything I have filled out is true to the best of my knowledge.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

Loading...