A1B healthcare

HIPPA Notice of Privacy Practice

A1B healthcare

HIPPA Notice of Privacy Practice

This notice describes how medical information about you may be used and described as well as how you can get access to this information

Please contact A1B health clinic with any questions or concerns.

Our Obligation:

We are required by law to

Maintain the privacy of protected health information
Give you the notice of our legal duties and privacy practice regarding information about you
Follow the terms of our notice that is currently in effect

How we may use and disclose health information:

The following describes the ways we may use and disclose health information that identifies you. Except for the purpose described below, we will use and disclose health information only with your permission. You may revoke such permission at any time by writing to the A1Bhealth clinic.

For Treatment: We may use and disclose health information for your treatment and to provide you with related health care services.

For Payment: We may use and disclose Health information that we or others may bill and receive payment from you, any insurance company or a third party for the treatment and services you received.

For example, we may give your health plan information about you so that they will pay for your treatment.

For Health care operations: We may use and disclose health information for health care operation purposes. These uses and disclosures are necessary to make sure that all our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the care you receive is of the highest quality. We also may disclose information with other entities that have a relationship with you for their health acre operation activities.

Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services:

We may disclose health information to contact you to remind you that you have an appointment with us. We also may use and disclose health information to tell you about treatment alternatives or health benefits and services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care:

We may share health information with person who is involved in your medical care or payment for your care such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

Consent to treat- Please read carefully
I herby authorized evaluation and treatment by the physician and staff associated with A1B health care clinic. I understand and agree that the signatures and dates on this from will not expire without written notice or in the case that a minor becomes the age of 18, and that a photocopy of this form is considered valid as original
Patient Name*
D.O.B*
Patient (Signature)*
Date*
Acknowledgment of Receipt of HIPPA Notice of Privacy Practice I herby acknowledge that I have received the Notice of Privacy practice from the A1B health clinic.
Patient Name*
Date*
Patient (Signature)*
Clients Rights and Responsibilities
We are committed to serving you with compassion, care and respect. As one of our valued clients you are entitled to the following: You have the right: To be treated with respect and dignity To privacy and confidentiality To receive accurate information about your health-related concern To know the effectiveness and potential side effects of all forms of treatment To participate if choosing the treatment best suited for you To receive educational and counseling about treatment You have the responsibility: To seek medical attention promptly and provide useful feed back To be honest about your medical history To ask questions about anything you do not understand To follow health, advise and instructions To be honest about your sun exposure, your health history including not limited to allergies to medications, medications taking, medical and surgical histories. To show up to appointment or cancel 48 hours in advance I authorize the A1B health clinic to perform the treatment or procedure recommended. I acknowledge no guarantee; either expressed or implied has been made to me regarding the outcome of any treatment process. I fully understand it is impossible for anyone to make a guarantee regarding the outcome of any medical treatments or procedures. I understand I am financially responsible for l procedures due when services are rendered, and for any appointment I failed to attend without 48 hours’ notice.
CLIENT SIGNATURE*
Date
Reviewed by
Date
A1B HEALTH CARE
PATIENT INFORMATION
Name
First Middle Last
D.O.B
SEX
MAILING ADDRESS:
Street Address Address Line 2 City State ZIP Code
PREFERRED LANGUAGE
MARITAL STATUS:
MAY WE LEAVE MESSAGES ON YOUR ANSWERING MACHINE
- Yes
- No
OCCUPATION
Insurance name and ID
Insurance holder name
Insurance Phone
RELATIONSHIP
EMERGENCY/NEXT OF KIN PHONE
HOW DID YOU HEAR ABOUT US?
PATIENT HISTORY QUESTIONNAIRE
Primary Care Physician
Clinic Name/Phone
List any allergies you have including medications, food or any other negative reaction and type of reaction. ❐ NKDA (No Known Drug Allergies) Allergies: List any medications you are currently taking, including over the counter medication. Please list medication strength and how often you take the medication:
Please Note: If you do not know the medication, please call your pharmacy. We are unable to provide care without a current medication list.
Pharmacy Information
what may be able to send your prescription directly to your pharmacy. Please list the pharmacy where you want your prescription sent. List all long term or recurring medical problems.
List any kind of surgery you have had
The following individuals are authorized to speak to regarding my health information.
Name / Relationship Name
PATIENT SIGNATURE*
RELATIONSHIP IF OTHER THAN THE PATIENT
Date

A1B healthcare

Consent to treat- Please read carefully

Clients Rights and Responsibilities

A1B HEALTH CARE

PATIENT HISTORY QUESTIONNAIRE

The following individuals are authorized to speak to regarding my health information.