Please print and fill out the patient
information and medical history form before your initial appointment
In order to make your visit less time consuming, we ask that you
print and fill out
the Patient Information Forms. Please bring them with you when you come in for your appointment.
Filling out
these forms will enable us to serve you better and faster.
You will need to download and install Adobe® Acrobat Reader version 5.0
or later to use and fill out this form. After Adobe® Acrobat Reader is installed on your
computer, download the form by clicking the PDF icon link below. Once the form is downloaded,
please print it, fill it out and bring it with you to your appointment.
Click on the PDF icon to download and print the Patient Information and Medical History Form.
Click on the PDF icon to download and print the HIPAA form for your
records.
HIPAA NOTICE OF
PRIVACY PRACTICES
Effective date: April 14, 2003
We understand that health information about you and your health is
personal. We are committed to protecting health information about you.
We create a record of the care and services your receive from us. We
need this record to provide you with quality care and to comply with
certain legal requirements. This Notice applies to all of the records of
your care generated by this office, whether made by your personal doctor
or others working in this office. This notice will tell you about the
ways in which we may use and disclose health information about you. We
also describe your rights to the health information we keep about you,
and describe certain obligations we have regarding the use and
disclosure of your health information.
We are required by law to:
Make sure that health
information that identifies you is kept private.
Give you this Notice of our
legal duties and privacy practices with respect to health
information about you.
Follow the terms of the
Notice that is currently in effect.
How we may use and disclose health information about you:
For treatment.
For payment.
For health care operations.
For appointment reminders.
As required by law.
To avert a serious threat
to health and safety.
As required by the Military
or Veterans and Workers Compensation.
Public Health risks.
Health oversight activities.
Lawsuits and disputes.
Law enforcement.
Coroners, health examiners
and funeral directors.
National Security and
Intelligence activities.
Protective Services for the
President and others.
Security Officials for
Inmates.
Your rights regarding Health Information about you:
Right to inspect and copy.
Right to amend.
Right to an Accounting of
Disclosures.
Right to Request
Restrictions.
Right to Request
Confidential Communications.
Right to a Paper copy of
this Notice (full
Notice is available upon request).
Changes to this Notice:
We reserve the right to change this Notice. We will post a copy of the
current notice in our facility with the current effective date on the
first page.
Complaints:
If you believe that your privacy rights have been violated, you may file
a complaint with us. All complaints must be in writing. Please contact
the administrator at the location where you were treated to file a
complaint.
Acknowledgement of Receipt of this Notice:
We will request that you sign a separate form acknowledging you have
received a copy of this notice. This acknowledgement will become a part
of you records.
We may use and disclose your information to conduct or arrange for
services including:
Medical quality review by
your health plan.
Accounting, legal, risk
management, and insurance services.
Audit functions, including
fraud and abuse detection and compliance programs.
Your Health Information Rights:
The health and billing records we create and store are the property of
the practice/health care facility. The protected health information in
it, however, generally belongs to you. You have the right to:
Receive, read, and ask
questions about this Notice.
Ask us to restrict certain
uses and disclosures. You must deliver this request in writing to
us. We are not required to grant the request, but we will comply
with any request granted.
Request and receive from us
a paper copy of this or the most current Notice o Privacy Practices
for protected Health Information (“Notice”).
Request that you be allowed
to see and get a copy of your protected health information. You may
make this request in writing. We have a form available for this type
of request
Have us review a denial of
access to your health information—except in certain circumstances.
Ask us to change your
health information. You may give us this request in writing. You may
write a statement of disagreement if your request is denied. It will
be stored in your medical record, and included with any release of
your records.
When you request, we will
give you a list of disclosures of your health information. The list
will not include disclosures to third-party payors. You may receive
this information without charge once every 12 months. We will notify
you of the cost involved if you request this information more than
once in 12 months.
Ask that your health
information be given to you by another means or at another location.
Please sign, date and give us your request in writing.
Cancel prior authorizations
to use or disclose health information by giving us a written
revocation. Your revocation does not affect information that has
already been released. It also does not affect any action taken
before we have it. Sometimes, you cannot cancel an authorization if
its purpose was to obtain insurance.
For help with these rights during normal business hours, please contact
the administrator of the location at which you have been treated. Please
call the main office phone number and ask for the administrator.
Our Responsibilities
We are required to:
Keep your protected health
information private.
Give you this Notice.
Follow the terms of this
notice.
We have the right to change our
practices regarding the protected health information we maintain. If we
make changes, we will update this Notice. You may receive the most
recent copy of this Notice by calling and asking for it or by visiting
our office to pick on up.
To Ask for Help or Complain
If you have questions, want
more information, or want to report a problem about the handling of your
protected health information, you may contact
the administrator of the location at which you have been treated. Pleas
call the main office phone number and ask for the administrator.
If you believe your privacy
rights have been violated, you may discuss your concerns with any staff
member. You may also deliver a written complaint to the administrator at
you practice/health care facility. You may also file a complaint with
the U.S. Secretary of Health and Human Services.
We respect your right to file a
complaint with us or with the U.S. Secretary of Health and Human
Services. If you complain, we will not retaliate against you.
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Other Disclosures and Uses of Protected Health Information
Notification of Family and Others
Unless you object, we may
release health information about you to a friend or family member who is
involved in your medical care. We may also give information to someone
who helps pay for your care. We may tell your family or friends your
condition and that you are in a hospital. In addition, we may disclose
health information about you to assist in disaster relief efforts.
You have the right to object to
this use or disclosure of you information. If you object, we will not
use or disclose it.
We may use and disclose your protected health information without
your authorization as follows:
With Medical
Researchers—if
the research has been approved and has policies to protect the
privacy of your health information. We may also share information
with medical researches preparing to conduct a research project.
To Funeral
Directors/Coroners consistent with applicable
law to allow them to carry out their duties.
To Organ Procurement
Organizations (tissue donation and transplant)
or persons who obtain, store, or transplant organs.
To the Food and Drug
Administration (FDA) relating to problems with
food, supplements, and products.
To Comply with Workers’
Compensation Laws—If
you make a workers’ compensation claim.
For Public Health and
Safety Purposes as Allowed or Required by Law:
to prevent or reduce a
serious, immediate threat to the health or safety of a person.
or the public.
to public health or
legal authorities.
to protect public
health and safety.
to prevent or
control disease, injury, or disability.
to report vital
statistics such as births or deaths.
To Report Suspected
Abuse or Neglect to public authorities.
To Correctional
Institutions if
you are in jail or prison, as necessary for your health and the
health and safety of others.
For Law Enforcement
Purposes such as
when we receive a subpoena, court order, or other legal process, or
you are the victim of a crime.
For Health and Safety
Oversight Activities. For example, we may share
health information with the Department of Health.
For Disaster Relief
Purposes. For
example, we may share health information with disaster relief
agencies to assist in notification of your condition to family or
others.
For Work-Related
Conditions That Could Affect Employee Health. For example, and employer
may ask us to assess health risks on a job site.
To the Military
Authorities of U.S. and Foreign Military Personnel. For example, the law may
require us to provide information necessary to a military mission.
In the Course of
Judicial/Administrative Proceedings at your request, or as
directed by a subpoena or court order.
For Specialized
Government Functions. For example, we may share
information for national security purposes.
Other Uses and Disclosures of Protected Health Information
Uses and disclosures not in
this Notice will be made only as allowed or required by law or with
your written authorization.
Effective Date:
April 14, 2003
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You will be asked to sign this HIPAA Consent
Form at the time of your initial appointment
PLEASE
COMPLETE THIS FORM
By my signature below I acknowledge receipt of the notice of
the Privacy Practices of
Strait Orthopedic Specialists, P.S.
1._______________________________
2.___________________________________
Print the Patient’s Name
Signature of patient or authorized individual
3._____________________________
4.(This person)________________________
Your relationship to this patient
Has my permission to receive my medical inf
5.___________________________
6. ______________________
Today’s Date
Strait Ortho Patient Acct #
