New Patients Form

Dear Sir or Madam:

At your first visit, you will undergo a complete evaluation and your medical history will be reviewed. Any necessary diagnostic testing or further medical evaluation will then be discussed with you and orders provided.

The remaining pages comprise our new patient paperwork and we need you to print these forms and complete them prior to your visit. Please bring the following items with you to your first visit:

• The completed new patient forms.
• ALL insurance cards.
• Your driver’s license or other picture identification.
• A list of your current medications (we will require this EACH visit).
• Any diagnostic reports, physician office notes, or hospital records regarding the current condition for which you are being seen.
• If you have an HMO or POS plan you will need to get a referral from your primary care physician. Without this referral - you will be required to pay in full for the visit. A current authorization is necessary for EACH visit and is the responsibility of the patient.
• Payment is expected at the time of service. Any co-pay, co-insurance or unmet deductible will be collected at the time of your visit. We accept all major credit cards.

Due to the congested traffic patterns in the medical center and limited parking, we suggest that you allow PLENTY of time to arrive in the office at least 30 minutes prior to your scheduled appointment time. This 30 minute pre-visit period is necessary to prepare your chart, review HIPAA protected healthcare information, and give us time to get you ready for your consultation with the doctor.

Since we must schedule patient appointments efficiently, and we wish to give each patient the care and attention that they deserve, it may be necessary to reschedule your appointment to another date if you arrive late.

Please give us at least 48-hours notice if you must cancel or reschedule your appointment; this allows us the opportunity to offer your appointment time to another patient.

Please call our office if you have any questions.

Sincerely,

Rosa Alvarez
Office Coordinator

Registration Form

In case of an emergency, who should be notified?

Please list other doctors you have seen in the past 5 years:

Assignment and Release

I, the undersigned, have insurance coverage with (Name of Insurance Company Stated Above) and assign directly to Houston M.D.s, P.A. all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic. 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.

Medicare Authorization

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Houston M.D.s, P.A. for any services furnished to me by these physicians. I authorize any holder of my medical information to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payments be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes release of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier. 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.

History of Present Illness

Introduction

Present Illness

Please check all the following that apply to you with regard to this visit only.

Medications

If you are allergic to any medications or drugs please list them, with the type of reaction:

List any medication you are taking at this time:

Past Medical History

Surgical History

Please list any previous operations you have had:

Previous Operations

Family History

If Living

If Deceased

Do you know of any blood relative that has had any of the following (Please specify your relationship to the said relative):

Social History

Habits

Contact me at the following telephone numbers:

Fill out the preferred contact number:

Authorization to discuss Private Health Information with the following Family member or other designated Person.

Pinky S. Tiwari, M.D. OR James M. Wilson, M.D. may discuss my health information, if necessary, with
the following persons without my written permission at each occurrence.

Authorization to obtain/release Information.

Authorization to leave Messages.

Authorization for Billing.

General consent for treatment.

I have read, understand and had the opportunity to ask questions regarding the Health Information
Privacy Practices of Pinky S. Tiwari, M.D. and James M. Wilson, M.D.

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 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. 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?

What Information can be Disclosed?

Your initials are required to release the following information:

Reason for Disclosure

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)(1). 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.

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.

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).

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 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 (HIPAA) 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, healthcare 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 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,” “health care 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, tests, 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).
• Drug, 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 healthcare 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 health care 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)(1)(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), (4)).

Limitations of this form - This authorization form shall not be used for the disclosure of any health information as it relates to: (1) health benefits plan enrollment and/or related enrollment determinations (45 C.F.R. § 164.508(b)(4)(ii), .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 use of 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 Code § 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.