South Coast Family Medicine
We will need to make a copy of Insurance Card and Photo ID
Necesitaremos Hacer Copias De Su Identificacion y Tarjeta de Seguro
PLEASE BRING ALL MEDICATIONS TO ALL APPOINTMENTS
POR FAVOR DE TRAER TODAS SUS MEDICINAS A CADA VISITA
IF YOU ARE NOT THE PRIMARY INSURED PLEASE PROVIDE INFO FOR CARD HOLDER:
Si No Eres La Persona Primaria En El Aseguro Por Favor Proveer la Siguiente Informacion Del Asegurado Principal:
Preferred Pharmacy (Please include Name and Address):
Farmacia De Preferencia (Incluya El Nombre y Ubicacion):
I hereby consent for the clinic to photograph my care, treatment, and services and allow the clinic to use the photographs for their internal use, for documenting my medical condition or for insurance providers to document my condition for payment purposes.
Yo le doy permiso a la clinica de tomar photografias de mi cuidado, tratamiento, y servicios, la clinica puede usar las photografias para el uso interno para documentar mi condicion medica o para el uso de explicacion de mi condicion medica a las aseguransas para proposito de pago.
DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize South Coast Family Medicine or insurance company to release any information required to process my claim.
La información anterior es verdadera a lo mejor de mi conocimiento. Autorizo a mis beneficios de seguro a pagar directamente al médico. Entiendo que soy financieramente responsable por cualquier saldo. También autorizo a South Coast Family Medicine o compañía de seguros para liberar toda la información necesaria para procesar mi reclamo.
DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
***PLEASE NOTE: WE DO NOT PRESCRIBE PAIN MEDICATION ON THE FIRST APPOINTMENT***
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL
Exercise/Diet:
Salt Intake:
Alcohol:
Tobacco:
Drugs:
Father
Mother
Sibling
Children
Grandmother (Maternal)
Grandfather (Maternal)
Grandmother (Paternal)
Grandfather (Paternal)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This practice uses and discloses health information about you for treatment, for administrative purpose, and to evaluate the quality of care that you receive. We are required by law and regulation to protect the privacy of your medical information, to provide you with this notice of our privacy practices the respect to protected health information, and to abide by the terms of the notice of privacy practices in effect. This notice is effective 04/01/2015.
This notice describes our privacy practices. We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen. You can request a paper copy of this notice, or any revised notice, at any time.
A. Treatment, Payment, Health Care Operations
Treatment: We are permitted to use and disclose your medical information to those involved in your treatment. For example, your care may require the involvement of a specialist. When we refer you to that physician, we will share some or all of your medical information with that physician to facilitate the delivery of care.
Payment: We are permitted to use and disclose your medical information to bill and collect payment for the services we provided to you. For example, we may complete a claim form that will contain medical information, such as a description of the medical services provided to you, to obtain payment from your insurer or HMO.
Health Care Operations: We are permitted to use or disclose your medical information for the purpose of health care operations, which are activities that support the practice and ensure that quality care is delivered. For example, we may engage the services of a professional to aid this practice in its compliance programs. This person will review billing and medical files to ensure we maintain our compliance with regulations and the law.
B. Disclosures That Can Be Made Without Your Authorization: There are situations in which we are permitted to disclose or use your medical information without your written authorization or an opportunity to object. In other situations, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization, in written, to stop future uses and disclosures. However, any revocation will not apply to disclosures or uses already made or that rely on that authorization.
C. Your Right Under Federal Law
The U.S. Department of Health and Human Service created regulations intended to protect patient privacy as required by the Health Insurance Portability and Accountability Act (HIPAA). Those regulations create several privileges that patients may exercise.
Requested Restrictions:
Receiving Confidential Communication by Alternative Means: We may contact you by telephone, mail, or both to provide appointment reminders, information about treatment alternatives, or other health-related benefits and services that may be of interest to you. You may request that we send communications of protected health information by alternative means or to an alternative location. This request must be made in writing to the person listed below. We are required to accommodate only reasonable requests. Please specify in your correspondence exactly how you want us to communicate with you and the contact and address information.
Inspection and Copies of Protected Health Information: You may inspect and/or copy health information that is within your medical record that is used to make decisions about your care. Texas laws requires that requests for copies be made in writing, and we ask that request for inspection of your health information also be made in writing. Please send your request to the person listed at the end of this document. There are certain situations in which we are not required to comply with your request. Under these circumstances, we will respond to you in writing, stating why we will not grant your request and describe any right you may have to request a review of your denial. Texas law requires us to be ready to provide copies within 15 days of your request. We will inform you when the records are ready or if we believe access should be limited. HIPAA permits is to charge a reasonable cost-based fee for copying your chart.
Amendment of Medical Information: You may request an amendment of your medical information in the designated record set. Any such request must be made in writing to the person listed at the end of this document and must explain your reason for the amendment. We will respond within 60 days of your request. We may deny your request for the following reasons: the information was not created by this practice or the physicians in this practice, the information is not part of the records used to make a decision about you, the information is not available for inspections because of an appropriate denial, or the information is accurate and complete.
If we refuse to allow an amendment, we will inform you in writing and you are permitted to include a statement in your chart about the information at issue in your medical record. If we approve the amendment, we will inform you in writing, allow the amendment to be made and tell others that we not have the correct information.
According of Certain Disclosure: HIPAA privacy regulations require us to provide at our request, an accounting of disclosures that are either for treatment, payment, health care operations, or made via an authorization signed by you or your representative. Please submit any request for and accounting to the person at the end of this document. If you request a list of disclosures more than once in 12 months, we are allowed to charge a reasonable fee.
Complaints: If you are concerned that your privacy rights have been violated, you may contact the person listed below. You may also send a written complaint to the U.S Department of Health and Human Services. We will not retaliate against you for filling a complaint with us or the government.
Questions and Contact Person for Requests: If you have any questions regarding the privacy notice, any complaints or concerns regarding this practice or any requests (pursuant to the rights describe above) please contact:
SOUTH COAST FAMILY MEDICINE
6182 Dunbarton Oak Dr., Suite B
Corpus Christi, Texas 78414
Ph: (361) 452-9320 Fax: (361) 452-9321
As a patient of South Coast Family Medicine, I understand that the following policies are currently in effect:
My signature confirms I have read and understand the above office policies and have had an opportunity to ask question regarding any concerns I may have about these policies.
DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
**This document may be obtained in Spanish version, per patient request. / Este documento puede ser obtenido en Espanol**
I have received a copy of the South Coast Family Medicine Notice of Privacy Acknowledgement. I understand that South Coast Family Medicine has the right to change its Notice of Privacy Practices from time to time and that I may contact South Coast Family Medicine at any time to obtain a current copy of the Notice of Privacy Practices.
DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
FOR OFFICE USE ONLY
Authorizes South Coast Family Medicine, to release the following information to:
Confer orally with person(s) listed below about my medical conditions: (family member, caregiver, etc)
This Authorization shall be valid from the date of signature. The patient can revoke this authorization in writing at any time.
DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Please release my records:
To:
South Coast Family Medicine
6182 Dunbarton Oak Dr., Suite B
Corpus Christi, Texas 78414
Office: (361) 452-9320
Fax: (361) 452-9321
Permission is hereby granted for RELEASE OF INFORMATION
***REQUIRED***
Please initial the following:
I recognize the information disclosed may contain mental health information that is protected by state and federal laws. I consent to the disclosure of this information.
I recognize the information released may contain drug/alcohol information that is protected by federal law. I consent to disclosure of such information.
I recognize the information disclosed may contain information regarding sexually transmitted disease or HIV/AIDS testing. I consent to disclosure of this information.
You have the right to revoke this authorization at any time, except to the extent that South Coast Family Medicine has already acted based on this authorization. To revoke this authorization, you must submit a request in writing to South Coast Family Medicine at the above address.
This authorization does not have an expiration date.
Your information will be encrypted.