Michelle Randolph MD PC
PLEASE INCLUDE A FRONT & BACK PHOTO COPY OF YOUR ID AND INSURANCE CARD WITH THIS FORM.
WE UNDERSTAND YOU MAY HAVE CONCERNED RELATIVES OR SIGNIFICANT OTHERS. PLEASE LIST NAMES OF THOSE PEOPLE THAT WE MIGHT SHARE YOUR MEDICAL INFORMATION WITH.
WITHOUT YOUR WRITTEN CONSENT, THIS INFORMATION WILL NOT BE RELEASED.
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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.
ALL CO-INSURANCE PAYMENTS ARE DUE AT THE TIME OF SERVICE. I UNDERSTAND THAT I AM RESPONSIBLE FOR OBTAINING A REFERRAL FROM MY PRIMARY CARE PHYSICIAN IF ONE IS REQUIRED. I ACCEPT FINANCIAL RESPONSIBILITY FOR ALL ACCOUNT BALANCES OVER 30 DAYS. ANY ACCOUNTS THAT ARE REFERRED FOR COLLECTION WILL BE CHARGED REASONABLE COLLECTION FEES AND ATTORNEY FEES. I AUTHORIZE THE DOCTOR TO RELEASE INFORMATION TO MY INSURANCE COMPANY. I AUTHORIZE ALL INSURANCE BENEFITS TO BE PAID DIRECTLY TO THE DOCTOR.
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.
SURGICAL HISTORY
FAMILY HISTORY - INCLUDE AGE OF DIAGNOSIS
SOCIAL HISTORY
ADDITIONAL SYMPTOMS
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 Notice describes the medical information practices of MICHELLE RANDOLPH MD PC. MICHELLE RANDOLPH MD PC is considered a covered entity, and therefore we are required by law to maintain the privacy of personal health information and to provide you with notice of our legal duties and privacy practices with respect to personal health information. All MICHELLE RANDOLPH MD PC departments or programs are covered by this Notice and your personal health information may be shared among these divisions.
We understand that medical information about your health is personal. We will not disclose your personal health information to others unless you tell us to do so, or unless the law authorizes or requires us to do so. This Notice applies to all of the medical records we maintain. It describes the ways in which we may use and disclose medical information, and describes our obligations with regard to such information.
We are required by law to:
We have the right to change our practices regarding the personal health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of the Notice by calling RACHELLE MELVIN, the Privacy Officer at
The following are some of the different ways that we may use and disclose your personal health information:
For Treatment. We may use or disclose medical information about you to facilitate treatment, rehabilitation or treatment through services provided by MICHELLE RANDOLPH MD PC. For example, we may disclose medical information to other healthcare providers who are involved in taking care of you.
For Payment. We may use and disclose medical information about you to get reimbursed for the services we provide to you, including such things as submitting bills to insurance companies (either directly or through a third party billing company), medical necessity determinations and reviews, and collection of outstanding accounts.
For Health Care Operations. We may use and disclose medical information about you for other MICHELLE RANDOLPH MD PC health care operations necessary to run MICHELLE RANDOLPH MD PC. For example, we may use medical information in connection with: conducting quality assessment and improvement activities; licensing; personnel training programs; fraud and abuse detection programs; and general MICHELLE RANDOLPH MD PC administrative activities.
To Business Associates. There are some services provided to MICHELLE RANDOLPH MD PC through contracts with business associates. Examples include accounting, legal, training, and consulting services. Information shall be made available to business associates consistent with their need to know for purposes of providing services.
Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.
As Required by Law. We will disclose medical information about you when required to do so by federal, state or local law. For example, we may disclose medical information when required by a court order.
To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of another person. Any disclosure, however, would only be to someone able to help prevent the threat.
We may also use and disclose your health information in the following circumstances, when permitted by law, and with only the minimum necessary information being disclosed:
Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization. This includes the use or disclosure of psychotherapy notes, the use or disclosure of PHI for marketing, or the sale of PHI, which will require your express written authorization.
You have the following rights regarding medical information we maintain about you:
If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. Your substance abuse records received by a person or entity pursuant to your written authorization may not be re-disclosed without your written consent.
If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. Your substance abuse records received by a person or entity pursuant to your written authorization may not be re-disclosed without your written consent.
If you have any questions about this Notice or would like to exercise any of the rights contained herein, please contact: RACHELLE MELVIN, Privacy Officer, 2741 DeBarr Road, Anchorage AK, 907-531-5213.
If you believe your privacy rights have been violated, you may file a complaint with MICHELLE RANDOLPH MD PC or with the Secretary of the Department of Health and Human Services. To file a complaint with MICHELLE RANDOLPH MD PC, contact the Privacy Officer. All complaints must be submitted in writing. You will not be retaliated against or penalized for filing a complaint. The Secretary of DHHS can be reached at:
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
By my signature below, I acknowledge that I have received Notice of Privacy Practices and Client Rights, and that I understand and have had an opportunity to ask questions about the Notice.
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.
We are a small solo practice. In order to serve our patients well we ask that you inform us of procedure cancellations at least four days prior to your procedure. If you do not inform us, you will be charged a $100 cancellation fee. Your insurance will not be billed. You will be responsible for this fee.
I acknowledge and agree to the cancellation policy.
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