New Patients In-Take

• Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
• It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
• The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
• You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
• You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
• Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
• We agree to provide patients with access to their records in accordance with state and federal laws.
• We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
• You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

Financial Policy

• All medication requests, if approved, will be filled within 72 hours (usually sooner) after the request has been received either from the pharmacy or the patient. It is important that patients monitor the amount of medication remaining in their current prescriptions in order to avoid running out of medicine before a refill can be called in.
• Without written authorization from the doctor, a patient who has not yet been examined within the preceding 90 days and is requesting refills of medication may not have the medication refilled.
• If a request for a medication refill has been denied, the patient will be notified as soon as possible and will be given the reason why the medication will not be refilled. The patient may be directed to schedule an appointment for examination in order to ensure that the medication requested is, in fact, still appropriate for their condition.
• In connection with certain medications, the patient may be requested to have a blood test every three to six months to allow continued usage of the medications.
• Medication refill requests will be taken and processed during normal office hours only.
• NO narcotic pain medication will be prescribed.
• Narcotic pain medication is used for acute pain, such as that associated with recent injury or surgery, and are not used for the management of long-term or chronic pain. A referral to one of several pain management groups is available for patients in need of long-term management.
  After reviewing the protocol, I understand and agree to its provisions.

Indications for Use

Side Effects

Warnings and Precautions

Introduction

• Patient medical records
• Medical images
• Live two- way audio and video
• Output data from medical devices and sound and video files

Expected Benefits

• Improved access to medical care by providing care to patient even if the physician is at distant / other sites
• More efficient medical evaluation and management.
• Obtaining expertise of a distant specialist.

Possible Risks

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician.
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
• In very rare instances, security protocols could fail, causing a breach of privacy of personal information.
• In rare cases, a lack of access to complete client records may result in adverse drug interactions or allergic reactions or other judgement errors.

By Signing This Form, I Understand The Following:

• I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identities me will be disclosed to researchers or other entities without my consent.
• I understand that telemedicine may involve electronic communication of my personal information.
• I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but no results can be guaranteed or assured.