New Patient Form - Adult

Please correct the errors described below.
Fecha
Nombre del Paciente
Fecha del Nacimiento
Direccion del Paciente
Seguro Social
Telefono
Farmacia del Paciente
Nombre del duendo de aseguranza
Fecha de Nacimiento del Asegurado
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      Staff Use Only

      I, as the patient or legal guardian of the patient, verified the information given here is correct and complete. I understand that cancellations and refunds must be approved in writing by the clinic manager.

      Yo, como paciente o guardia legal del paciente, verifico quela informacion escrita aqui es correcta y completa. Yo entiendo que reembolsos y cancelaciones de pago requieren ser aprovadas por escrito por el manager.

      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.

      (DESCARGO DE RESPONSABILIDAD: Al escribir su nombre a continuación, está firmando esta solicitud electrónicamente. Acepta que su firma electrónica es el equivalente legal de su firma manual en esta aplicación.)

      Firma

      Staff Use Only

      Patient Consent to Treat and Procedure

      I hereby give my consent to Lawndale Medical Clinic and authorize them to provide my medical treatment and procedure. I understand that Lawndale Medical Clinic will explain my condition(s), foreseeable risks, and methods of treatment for my condition before treatment and/or procedure is provided. I authorize Lawndale Medical Clinic to perform any additional or different treatment and or procedure that is thought necessary if, in an emergency situation, a condition is discovered that was not known previously.

      I have carefully read and I fully understand this Patient Consent to Treat and Procedure form and will have the opportunity to discuss my condition and the procedure(s) with the care provider. All my questions well be adequately answered.

      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.

      Por medio de esta forma Yo doy mi consentimiento y autorization a Lawndale Medical Clinic de proveer mi tratamientoy procedimiento medico. Yo entiendo que Lawndale Medical Clinic me explicara mi condicion(es) medica, riesgos previsibles, y metodos para tratar mi condicion antes de recibir el tratamiento o procidimiento. Yo autorizo a Lawndale Medical Clinic de realizar cualquier otro tratamiento o procedimiento adicional si es necesario en aso de alguna situacion de emergencia que se descubriera una condicion medica que no se conocia anteriormente.

      Yo cuidadosamente lei y entiendo completamente esta forma de Consentimento de Tratamiento y Procedimiento. Yo tendre la opotunidad de hablar con mi proveedor medico sobre mi condicion(es) medica y procedimientos necesarios. Todas mis pregustas seran adecudamente respondidas.

      DESCARGO DE RESPONSABILIDAD: Al escribir su nombre a continuación, está firmando esta solicitud electrónicamente. Acepta que su firma electrónica es el equivalente legal de su firma manual en esta aplicación.

      Patient Consent for H.I.P.P.A. Disclosure to Friend or Family Member

      These discussions may occur in person or via telephone.

      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.

      Forma de Consentimienta de H.I.P.P.A. para un Amigo or Familiar

      DESCARGO DE RESPONSABILIDAD: Al escribir su nombre a continuación, está firmando esta solicitud electrónicamente. Acepta que su firma electrónica es el equivalente legal de su firma manual en esta aplicación.

      Telemedicine Informed Consent

      Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.

      1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
      2. I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.
      3. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
        1. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
      4. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.
        1. I may revoke my right at any time by contacting Lawndale Medical Clinic at 713-924-4907.
      5. I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.
      6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
        1. I understand that my insurance carrier will have access to my medical records for quality review/audit.
        2. I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my telemedicine visit.
        3. I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits.
      7. I understand that this document will become a part of my medical record.

      By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and (3) am located in the State of Texas and will be in Texas during my telemedicine visit(s).

      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.

      Acknowledgement of Review of Notice of Privacy Practices

      I have reviewed this office Notice of Privacy Practices, which explain how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.

      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.

      Yo he revisado la notifcation de Practica Privada, la cual explica como mi information medica sera utilizada y revelada. Yo entiendo que tengo derecho de recibir una copia de este documento.

      DESCARGO DE RESPONSABILIDAD: Al escribir su nombre a continuación, está firmando esta solicitud electrónicamente. Acepta que su firma electrónica es el equivalente legal de su firma manual en esta aplicación.

      Your information will be encrypted.

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