EFTA00310781.pdf

Elise M. Brettlill. Jeffrey I. Mechanick, M.D. ION PATIENT INFORMAT E.-PSit -11•1 Social Security # Name: j RaN J Pip1 • QC 1 I g 3 Date of Birth: Street: q EAST - 4- VI 51. Zip:LOVZi Sex: F N State:t4 City: Partnered Spouse's Name: Marital Status: M D W NM a INI I Cell Phone: Home Phone: Employer: Ci& A Al & AL-12LAS1 Occupation: I44 Fax: Business PhonernilMaill01 Phone: Pharmacy: Address: Phone: Primary Care Physician: Relationship: Emergency Contact: Business Phone: Home Phone: Phone:_ Referred by: 1YR_ EVft 41,1bE12---SSe)i RIMARY INSURANCE Heat m- ?LAN). e . g13- -i eiti Late Insured TE,Fc--- ge9 Policy #: Group # Relationship to Patient: se Li-: b-FP:porbe__Ae Insurance Co: Ltb..) j.TE 9s3 Date Address:To -sot i4-4R0 0 SS# A ts.1 TA State:4A Zip:10S94- City: PC t.- Cep 0 E SECONDARY SURANC IN Group # Insured Policy: Relationship to Patient Insurance Co: Date of Birth Address: State Zip: SS#: City: furnish information M. D. and Elise M. Brett, M.D. to s I hereby authorize Jeffre y I. Me cha nic k, nce car rie rs. I aut hor ize payment of medical benefit treatment to my ins ura for any pan concerning my illness and M. Bre tt, MD . I und erstand that I am responsible M.D. and Eli se to Jeffrey I. Mechanick, ge. covered by medical covera of the charges that are not Date: Signed : ient is a minor) (Parent or Guardian if pat r/rri AJMISPIPIA:ol )S1P IPR PIP rts EFTA00310781  SAMPLE HIPAA PRIVACY NOTICE example, a doctor IlCatin INFORMATION one health care provider to another. For IS NOTICE DESCRIBES HOW MEDICAL for a broken leg may need to know if you have diabetes be w sOtIT YOU NIAY BE USED AND DISCLOSED AND HOW YOU . In addit ton. the doctor may N. PLEAS E REVIE W diabetes nay slow the healing process CAN GET ACCESS TO THIS INFOR MATIO physica l therapis t to Create the exert isc regimen mares to contact a IT CAREFULLY . cafe to your I RODLCTION Paisment means the activities vie undertake toobtain reimbursemc ons. c medical the health care provided to you, including billing, collecti linter' the name of the Practicel understands that yOur management. determ inations of eligibil ity and COW 3SC and oh, information ts pm ate and confidential Further. we art required by law to ng health care set health review activities. For example, prior to providi maintain he privacy of "protected health information" "Protected we may need to provide informa tion to your Third Party Pa tior s individ ually identifi able inform ation that we propose d cow intormairan include any your medica l conditio n to &leoni ne whethe r the physical obtain from you or others that relates to your past. present or future treatment will be cohered. When we subseq uently hill the Third for your nr menial health. the health care you have recewed, or payment Payer for the services rendere d to you. we can provide the Third necessary to c health Gait Payer with information regarding your care if a written payment. Federal or State law may require us to obtain As iequired by law, this notice provides you with information prior to disclos ing certain special ly protected to from you about yes r rights and our legal duties and privacy practices with respect information for payment purposes. and we will ask you to sign the pi rya y of protected health informa tion. This name also discuss es the when necessa ry under applica ble law. information oci and disclosures we ti ill make of your protected health We Must COMply with the provisio ns of this notice as curren tly in effect. s of our pr terms of this notice from tune Health rare operations means the support function nurse the right to change the assuran ce acts although we health related to oectrotur and pcti Wilt. such as quality to time and to make the revised notice effective for all protected case management. receiving and respond ing to patient Corne a You cart always reques t a written copy of our audits. by in format On ..c maintain complaints. physicia n reviews . complia nce program s. notice from the e's Privacy Officer or you can trative act.i e current privacy planning, development, management and adminis most Practic . (Note: The access it on our website at ctiiMpIC. we may use your protecte d health information to et alum be include d only if the Practice has a may oho CO ix reference to the ebsite should performance of our stall' when caring for you We act many patients to decide what adds health information about we should offer, what Services ire not needed, and w service s addition, we may ro certain new treatments are effective. In V.I f EEO USES AND DISCLOSURES that identifi es you Rom yOur patient information 1 informa tion informa tion to study health ea for others can use the dexelentifitd WC Can use or disclose your protected health information health care deliver y withou t learnin g who you arc. tr pNiplei n health ra•r operati ons. For each of purposes of eatment. mid and d a descrip tion PROTECTED HE these categories of uses and disclosures. we have provide OTHER USES AND DISCLOSURES OF ure in every an et amp e below Howe% er, not every particular usc or disclos INFORMATION category ri ll be listed tion for net ation or management of In addition to using and disclosing your informa reelitounil means the provision, coordin your protecte d health rotor betwee n health care payment and health cart operations, we may use your health care, including consultations ng your care and referra ls for health care from in the following ways. providers regardi SAMPLE ACKNOWLEDGMENT provided with a copy of 'Insert nai , acknowledge that I have been Practicel's privacy notice. Date. , 200 provid Guide, the privacy regulations require health care (Note: As discussed in the Step 7 of the Privacy faith effort to obtain an individual's written with direct treatment relationships to make a good r) privacy notice at the time of the first service delive acknowledgement of his/her receipt of the Practice's included for the Practice's use for this purpose.! 'p. in emergencies). This sample acknowledgment is et 1001- Garfunkel. wild & Trans. PC 279851 2 £.2'd 6aLLTS212T6:01 L£12 MB 212 OW NDINIzIrlTh 1.q>14•MP:WOJ Cr .r.r • Tn.. EFTA00310782  Data HEALTH HISTORY - please check symptoms you currently have or have had since your last visit here. General Respiratory Neurological Unexplained weight loss! Cough / wheeze Headache gain Loud snoring / altered breathing Memory loss Unexplained fatigue / during sleep Fainting weakness Short of breath with exertion Dizziness Fall asleep during day No problems Numbness tingling when sitting Unsteady gait Fever, chills Gastrointestinal Frequent falls No problems Heartburn / reflux! indigestion No problems Blood or change in bowel Skin movement Allergitimmune New or change in mole Constipation Hay fever / allergies Rash / itching No problems Frequent infections No problems No problems Genitourinary Breast Leaking urine Psychiatric Breast lump / pain / nipple Blood in urine Anxiety stress / irritability discharge Nighttime urination or increased Sleep problem No problems frequency Lack of concentration Discharge: penis or vagina No problems Ears/Nose/Throat Concern with sexual function Nosebleeds, trouble No problems Women only swallowing Pre-menstrual symptoms (bloating Frequent sore throat, Musculoskeletal cramps, irritability) hoarseness Neck pain Problem with menstrual periods Hearing loss / ringing in Back pain Hot flashes / night sweats ears Muscle / joint pain No problems No problems No problems Men only Eyes Endocrine Erection problems Change in vision / eye Heat or cold sensitivity Lump in testicle pain ! redness No problems Prostate cancer No problems Enlarged Prostate Hematologic/Lymphatic No Problems Cardiovascular Swollen glands Chest pain / discomfort Easy bruising Palpitations (fast or No problems irregular heartbeat) No problems To the best ofmy knowledge, the above information is complete and correct. I understand that is my responsibility to inform my doctor in or my minor child ever have a change in health. I assign directly to Dr. Elise M. Brat andDr. Jeffrey I. Merhanick at 1192 Park Avenue, all insurances rendered. I understand1 am financially responsiblefor all charges. I also authorize the disclosure ofmedical records to other providers for the management ofmy care in the extent permitted by law. 1 request payment to be made directly to Dr. Elise M. Brett and Dr. Jeffrey I. Mechanick at 1192 Park Avenue on my behalf Signature Print DOB 2,2'd 6LLLLIS21216:oi L£12 1£8 212 OW NOINFAADA ARMAARP:w0J4 Ac:SI IIRP-RI-iin EFTA00310783