welcome to my office. - turner gynecological care · welcome to my office. you probably understand...

Welcome to my office. You probably understand if referred by your doctor to my office that this has happened with the understanding that surgery is at least one option you will have for consideration. As such I wanted to provide you with some background information as well as some expectations I have as we move forward. Please take a moment to read the following information with particular attention to the last section of our care agreement.

My Background: I was born and raised in Arizona. Following high school I attended Brigham Young University on a football scholarship and subsequently served for two years as a missionary of The Church of Jesus Christ of Latter-day Saints in Brazil, Uruguay and Paraguay. Upon my return I attended the University of Arizona earning a degree in chemistry and math. In Tucson I met my future wife and married in 1981. We have since become the parents of three bright, talented and charming children. At the University of Arizona School of Medicine, I earned my medical degree, while my wife earned her “PhT” (Push Hubby Through).

From 1987 to 1991 I trained in Obstetrics and Gynecology at the University of Nevada Affiliated Residency Training Program in Las Vegas. Upon completion of this basic training I pursued additional fellowship or postgraduate training in advanced pelvic surgery with emphasis in gynecologic oncology (cancer), pelvic reconstruction (prolapse), urological (bladder repair), colorectal (intestinal surgery) and advanced endoscopic (minimally invasive) surgery.

Upon completion I was hired by the Residency Training Program to teach residents in advanced gynecologic surgical procedures until 1995 when I left the School of Medicine for private practice. In 2000 the Residency Training Program asked me to return as the director of the Division of Gynecologic Oncology and Pelvic Reconstructive Surgery as an Associate Professor of Medicine. I continued in this capacity while continuing to see private patients for roughly three years when I returned to private practice. I have served as a consultant and instructor for U.S. Surgical Corporation and Ethicon, a division of Johnson & Johnson both major manufactures of laparoscopic instruments teaching residents in training as well as more seasoned surgeons in private and academic practices.

I hold dual board certifications by the American Board of OB/GYN and the American Association of Gynecologic Laparoscopists. My current practice consists primarily of the application of advanced surgical techniques, traditional as well as laparoscopic and robotic assisted procedures in the treatment of gynecologic cancers, urinary incontinence and prolapse procedures and even repairing fallopian tubes in an out patient setting for those who have had sterilization procedures in the past and now want more children.

How things will work: The first visit will establish the foundation for the rest of your care. You will be asked to fill out a form regarding your past medical history which we will sit down and review to familiarize me with your history. Please be complete and legible in filling out this form—I realize this request may sound a bit peculiar coming from a doctor—as it provides me with an organized mechanism to avoid missing important items in your history that could impact the quality of care I wish to provide. Please use my form without attachments.

Competence and compassionare alive and well.

manufacturers of laparoscopic instruments

Specializing in surgery, my goal is to provide safe and effective procedures. Depending on your health history I may recommend that you have a surgical clearance from your general physician or specialists such as a cardiologist. Surgical clearance means that a doctor has evaluated your general health and feels that it is reasonable to proceed with surgery. It does not guarantee that there will be no complications, but reduces the possibility of them occurring.

I also try to avoid situations where patients have what I call “frequent flyer” experiences in the operating room. For example if a patient has a precancerous polyp in the colon when being seen for an incontinence procedure I want to know this so I can address both problems at one time. This is what motivated me to pursue my particular surgical training.

I strive to help patients not only understand my recommendations for care, but to have some understanding as to why I make a recommendation. Additionally, when there exists more than one prudent option I try to present them in a fashion that does lead a patient to a particular choice. This sometimes can be frustrating for those who have been accustomed to doctors simply telling them what they need to do. You are encouraged therefore to digest what I share with you so you feel that you understand options along with their risks and benefits.

You may feel that you want to get a second opinion or to review what I have shared with your long trusted primary care doctor. I recognize that the glow from my head is from a receding hairline not a halo so if you would like additional input please feel free to do so and if your treatment involves radiation or chemotherapy my staff and I will be happy to arrange for a consultation.

Care Agreement: Before any surgery is done you will be asked to enter into an agreement with me regarding that care. We unfortunately live in a society where one cannot enjoy an evening of television without being repeatedly encouraged to file a lawsuit against one party or another. I carry insurance understanding that I am not infallible and may make an error causing harm to a patient. I would want that patient to be fairly compensated if that occurs. With the complexity of the human body and the technology we have to treat patients there are, however, recognized complications that can occur with any surgery which do not represent an error on the part of the surgeon. You will be counseled regarding many of these things and are encouraged to ask any questions you might have.

My staff and I will strive to provide you with the best care possible, to help you understand your options along with their benefits and risks and to feel comfortable with the care you will receive. My staff and I welcome you to our practice.

Received: Patient Signature:

Patient Information ~ Page 1Pl e a se com Pl ete a ll fi elds except those marked Physician’s Notes.

PATIENT NAmE: EmPLOYER:

ADDRESS: ADDRESS:

CITY: STATE: ZIP: CITY: STATE: ZIP:

SSN #: Date of birth: oCCUPatioN/PoSitioN:

HOME PHONE: CELL PHONE: WORK PHONE:

SPOUSE’S NAME: SPOUSE’S EMPLOYER:

ADDRESS (IF DIFFERENT): ADDRESS:

CITY: STATE: ZIP: CITY: STATE: ZIP:

SSN #: Date of birth: oCCUPatioN/PoSitioN:


IN CASE OF EMERGENCY NOTIFY (CHECK ONE): SPOUSE OTHER: PHONE:

INSU

RAN

CE

IN

FO

PRIMARY INSURANCE SECONDARY INSURANCE

Guarantor:

Insurance/administrator:

Member number:

Group number:

You

r o

th

er

do

ct

or

s

Please, have Dr. Turner keeP The following Physicians infor meD of my care:

Physician’s name sPecialTy coDe

referring physician:

other physician:

other physician:

All professional services rendered are charged to the patient. Payment is due at the time of service unless other arrangements have been made. Necessary forms will be supplied to help expedite insurance carrier payments.

INSURANCE AUTHORIZATION & ASSIGNMENT: I hereby authorize Dr. Turner to furnish information to insurance carriers concerning my illness and treatments, and I hereby assign to Dr. Turner all payments for medical services rendered to me or my dependents. I understand that I am responsible for any amount not covered by insurance.

RELEASE OF INFORMATION: I hereby authorize Dr. Turner to release medical information about my illness or treatment to any individual who gives the following passcode: ____________. I understand that I must notify Dr.. Turner’s office in writing if my passcode changes.

PAT I EN T SIGNAT U R E DAT E COM PL ET E D

PATIENT NAME:

ADDRESS: CITY: STATE: ZIP:


SSN: DATE OF BIRTH: EMAIL:

PREFERRED LANGUAGE: ETHNICITY: RACE:

PHARMACY NAME: PHONE:

ADDRESS OR CROSS STREETS: ZIP:

PRIMARY INSURANCE SECONDARY INSURANCE

Guarantor:

Insurance:

ID number:

Group number:

PHYSICIAN’S NAME SPECIALTY PHONE

Referring physician:

Other physician:

Other physician

GUARANTOR NAME:

ADDRESS: CITY: STATE: ZIP:


SSN: DATE OF BIRTH: RELATIONSHIP:

IN CASE OF EMERGENCY NOTIFY: PHONE: RELATIONSHIP:

PAT

IEN

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FOPH

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INFO

INSU

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INFO

YOU

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FIRST LAST MI

FIRST LAST MI

PLEASE, HAVE DR. TURNER KEEP THE FOLLOWING PHYSICIANS INFORMED OF MY CARE:

INSURANCE AUTHORIZATION & ASSIGNMENT: I hereby authorize Dr. Turner to furnish information to insurance carriers concerning my illness and treatments and I hereby assign to Dr. Turner all payments for medical services rendered to me or my dependents. I understand that I am responsible for any amount not covered by insurance.

RELEASE OF INFORMATION: I hereby authorize Dr. Turner to release medical information about my illness or treatment to any individual who gives the following passcode: ____________. I understand that I must notify Dr. Turner’s office in writing if my passcode changes.

PRIVACY PRACTICES: By initialing here: ______ I acknowledge receipt and review of Dr. Turner’s Notice of Privacy Practices.

OFFICE AND FINANCIAL POLICY: By initialing here: ______ I acknowledge receipt and review of Dr. Turner’s Office and Financial Policy and agree to its contents.

______________________________________________________________________ PATIENT SIGNATURE DATE COMPLETED

# OF TIMES PREGNANT

# OF TER M DELIVERIES

# OF PRETER M DELIVERIES

# OF ELECTIVE ABORTIONS

# OF MISCARRIAGES

# OF LIVING CHILDREN

Date of last menstrual period: / /

Age when periods began:

Average number of days bleeding during cycle:

Average number of days between periods:

Are you currently sexually active? YES NO

If not, have you ever been sexually active? YES NO

Total number of sexual partners (lifetime):

Current method of birth control:

Date of last pap smear: / /

Was the pap smear result normal? YES NO

Have you ever had an abnormal pap smear? YES NO

Have you had problems with your uterus? YES NO

Have you had problems with your ovaries? YES NO

Are your periods excessively painful? YES NO

Do you still have pain when off your period? YES NO

Do you have pain with sex? YES NO

Do you ever lose urine unexpectedly? YES NO

If so, does this happen mostly when sneezing? YES NO

Have you ever had a sexually transmitted disease? YES NO


Full name: age: today’s date:

CC: H PI:

PHYS

ICIA

N’S

NO

TE

S

PHYSICIAN’S NOTES

AGE AT TIME OF DELIVERY

BABY”S NA ME

OUTCOME (CIRCLE ONE)

V C/S A M

V C/S A M

V C/S A M

V C/S A M

V C/S A M

V C/S A M

V C/S A M

V C/S A M

V C/S A M

V C/S A M

BABY WEIGHT

COMPLICATIONS

V = VAGINAL C/S = C-SECTION A = ABORTION M = MISCARRIAGE

PRE

GN

AN

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SG

YN

EC

OLO

GIC

HIS

TO

RY

Patient Information ~ Page 3Pl e a se com Pl et e a ll fi elds except those marked Physician’s Notes.

AGE AT TIME OF SURGERY PROCEDUR E PERFOR MED COMPLICATIONS

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

SUR

GIC

AL

HIS

TO

RY

DRUG DOSE AND FR EQUENCY PR ESCRIBING PHYSICIAN

ME

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PHYS

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N’S

NO

TE

S

HEART DISEASE: heart attack, stroke, YES NO rheumatic fever, arrhythmia, etc.

LUNG DISEASE: YES NO pneumonia, chronic bronchitis, etc.

LIVER DISEASE: hepatitis, etc. YES NO

KIDNEY/BLADDER DISEASE: YES NO failure, recurrent infections, stones, etc.

INTESTINAL DISEASE: YES NO gall bladder, ulcers, colitis, bleeding, etc.

DIABETES YES NO

HIGH BLOOD PRESSURE YES NO

SEIZURES YES NO

CANCER (or precancerous) DISEASE YES NO

THYROID DISEASE YES NO

GLAUCOMA YES NO

ARTHRITIS OR PAINFUL JOINTS YES NO

BROKEN BONES YES NO

BLOOD CLOTS IN LEGS OR LUNGS YES NO

LUPUS (collagen vascular disease) YES NO

BLOOD TRANSFUSION YES NO

PHYSICIAN’S NOTES

PER

SON

AL

ME

DIA

L H

IST

OR

Y

Have you ever smoked? YES NO

Do you currently smoke? YES NO

Number of years smoked?

How old were you when you quit?

Do you drink alcoholic beverages? YES NO

Average weekly consumption:

Type of alcohol:

To

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DRUG R EACTION(S) TO DRUG

DR

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S


AGE AT TIME OF SURGERY PROCEDUR E PERFOR MED COMPLICATIONS

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

SUR

GIC

AL

HIS

TO

RY

DRUG DOSE AND FR EQUENCY PR ESCRIBING PHYSICIAN

ME

DIC

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PR

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AL

PHYS

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N’S

NO

TE

S

HEART DISEASE: heart attack, stroke, YES NO rheumatic fever, arrhythmia, etc.

LUNG DISEASE: YES NO pneumonia, chronic bronchitis, etc.

LIVER DISEASE: hepatitis, etc. YES NO

KIDNEY/BLADDER DISEASE: YES NO failure, recurrent infections, stones, etc.

INTESTINAL DISEASE: YES NO gall bladder, ulcers, colitis, bleeding, etc.

DIABETES YES NO

HIGH BLOOD PRESSURE YES NO

SEIZURES YES NO

CANCER (or precancerous) DISEASE YES NO

THYROID DISEASE YES NO

GLAUCOMA YES NO

ARTHRITIS OR PAINFUL JOINTS YES NO

BROKEN BONES YES NO

BLOOD CLOTS IN LEGS OR LUNGS YES NO

LUPUS (collagen vascular disease) YES NO

BLOOD TRANSFUSION YES NO

PHYSICIAN’S NOTES

PER

SON

AL

ME

DIA

L H

IST

OR

Y

Have you ever smoked? YES NO

Do you currently smoke? YES NO

Number of years smoked?

How old were you when you quit?

Do you drink alcoholic beverages? YES NO

Average weekly consumption:

Type of alcohol:

To

ba

cc

oa

lco

ho

l

DRUG R EACTION(S) TO DRUG

DR

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ALL

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MED

ICA

L H

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Y


When was your last cholesterol screening?

Was it Normal? YES NO

When was your last barium enema?


When was your last colonoscopy?


Do you have bloody or tar-like stool? YES NO

When was your last bone density tax?


Do you perform regular self breast examinations? YES NO

Have you noticed any changes? YES NO

When was your last mammogram?


PHYSICIAN’S NOTES

PRE

VE

NT

AT

IVE

CA

RE

Is there a history in your family of the following? Relation (i.e. maternal aunt) Age when diagnosed

BREAST CANCER: YES NO

OVARIAN CANCER: YES NO

COLON CANCER: YES NO

DIABETES: YES NO

HEART DISEASE: YES NO

HIGH BLOOD PRESSURE: YES NO

STROKE: YES NO

BLOOD CLOTS IN LEGS OR LUNGS: YES NO

HIGH CHOLESTEROL: YES NO

TUBERCULOSIS: YES NO

BIRTH DEFECTS: YES NO

ALZHEIMER’S DISEASE: YES NO

HIV/AIDS: YES NO

HEPATITIS: YES NO

OTHER: YES NO

AD

DIT

ION

AL

FAM

ILY

ME

DIA

L H

IST

OR

YPA

RE

NT

S &

SIB

LIN

GS PARENTS AND SIBLINGS: Cause of death (if deceased) Age (or age at death)

Is your mother living? YES NO

Is your father living? YES NO

# of siblings living:

# of siblings deceased:

test?

MED

ICA

L H

IST

OR

Y


REVIEW OF SYSTEMS

1. CONSTITUTIONAL

Unexplained weight gain: CURRENT PAST

Unexplained weight loss: CURRENT PAST

Unexplained fevers: CURRENT PAST

Unexplained fatigue: CURRENT PAST

2. EYES

Double vision: CURRENT PAST

Spots before eyes: CURRENT PAST

Unexplained visual changes: CURRENT PAST

3. NEUROLOGIC

Dizziness: CURRENT PAST

Seizures: CURRENT PAST

Numbness: CURRENT PAST

Trouble walking: CURRENT PAST

4. EAR, NOSE, THROAT

Ear aches: CURRENT PAST

Ringing in ears: CURRENT PAST

Chronic sinus problems: CURRENT PAST

Prolonged sore throat: CURRENT PAST

Mouth sores: CURRENT PAST

Dental problems: CURRENT PAST

5. CARDIOVASCULAR

Painful breathing: CURRENT PAST

Chest pain: CURRENT PAST

Difficult breathing with exertion: CURRENT PAST

Leg swelling: CURRENT PAST

Heart palpitations: CURRENT PAST

6. RESPIRATORY

Wheezing: CURRENT PAST

Spitting up blood: CURRENT PAST

Shortness of breath: CURRENT PAST

Chronic cough: CURRENT PAST

7. GASTROINTESTINAL

Frequent diarrhea: CURRENT PAST

Bloody stools: CURRENT PAST

Black tar-like stools: CURRENT PAST

Nausea, vomiting: CURRENT PAST

8. ALLERGIC, IMMUNOLOGICAL

Allergies, seasonal: CURRENT PAST

Other allergies: CURRENT PAST

PHYSICIAN’S NOTES

H AV E A N Y OF T H E FOL LOW I NG BE E N OF CONCER N TO YOU, PA ST OR PR E SE N T? C I RC L E A PPROPR I AT E A NS W E R .

9. GENITOURINARY

Blood in urine: CURRENT PAST

Pain with urination: CURRENT PAST

Urgency: CURRENT PAST

Frequency of urination: CURRENT PAST

Incomplete emptying: CURRENT PAST

Incontinence with cough: CURRENT PAST

Abnormal periods: CURRENT PAST

Painful intercourse: CURRENT PAST

10. MUSCULOSKELETAL

Muscle weakness: CURRENT PAST

11. SKIN, BREAST

Pain in breast: CURRENT PAST

Nipple discharge: CURRENT PAST

Mass or lump: CURRENT PAST

Rash: CURRENT PAST

Ulcers: CURRENT PAST

12. PSYCHIATRIC

Depression: CURRENT PAST

Frequent crying: CURRENT PAST

13. ENDOCRINE

Dry skin: CURRENT PAST

Abnormal thirst: CURRENT PAST

Hot flashes: CURRENT PAST

14. HEMATOLOGIC, LYMPHATIC

Frequent bruising: CURRENT PAST

Cuts don’t stop bleeding: CURRENT PAST

Enlarged lymph nodes: CURRENT PAST


REVIEW OF SYSTEMS PHYSICIAN’S NOTES



PH YSICI A N SIGNAT U R E DAT E COM PL ET E D

9. GENITOURINARY









10. MUSCULOSKELETAL


11. SKIN, BREAST




Rash: CURRENT PAST


12. PSYCHIATRIC



13. ENDOCRINE













Thank you for choosing us as your health care provider. It is our desire to provide you with the best possible care. The fol-lowing is a statement of our Office and Financial Policy which we request you read and sign prior to being seen.

PAYMENT IS DUE AT THE TIME OF SERVICE. WE ACCEPT CASH, CHECKS, VISA/MASTERCARD.

Although we try to assist our patients as much as possible with insurance requirements, due to the vast number of poli-cies and plans we are unable to do so in every case. We encourage you to check your insurance plan benefits, referral, and prior authorization requirements. Please be aware that although some patients can self-refer to a GYN doctor, treatment without a referral from your primary care physician may result in reduced benefits and a greater out-of-pocket expense to you. In addition, please be aware that your insurance plan may not cover routine screening and preventative care (annual pap smears, pelvic/breast exams, coloscreens, etc.) and you will be responsible for these charges.

We will bill your insurance company for all applicable visits and treatment provided. It is your responsibility to provide us with accurate insurance information so that we can file your claim with the correct insurance company using the correct billing information. If you have a secondary insurance plan, please let us know at the time of your visit.

Participating Provider As we are contracted with your insurance company, by law we are required to collect all co-pays, deductibles, and co-insurance. Payment is due at the time of service.

Non-Participating Provider/Indemnity Plans As a courtesy, we will bill your insurance company for you. As your insurance policy is a contract between you and your insurance company and we are not a party to that contract, the amount due for any service rendered is the total amount of the billed fee. We do not discount our fees based on what your insurance company determines is reasonable and customary. It is your responsibility to ensure we have your most current insurance information.

Cash Pay Patients Payment is due at the time of service. For a scheduled surgery, payment is due prior to surgery.

Medicare Patients Medicare does not cover preventative services. Medicare will cover a routine screening pap smear and a pelvic/breast exam once every three years. Medicare will cover these services yearly if you are considered high risk. They will cover a screening mammogram and coloscreen once a year. Please read your benefit booklet provided by Medi-care. You are responsible for preventive services and pap smears and pelvic/breast exams done more frequently than that allowed by Medicare. PLEASE NOTE: We follow medical recommendations for your treatment and care, not govern-mental reimbursement guidelines and as such you may be personally responsible for some services received.

Interest Interest will be charged at a rate of 12% per annum for all accounts over 30 days old.

Minor Patients The parent or guardian accompanying a minor is financially responsible for all services provided.

Missed Appointments Please help us serve you and our other patients better by keeping scheduled appointments. If you must cancel your appointment, please notify our office as soon as possible. Unless canceled at least 24 hours in advance your account may be charged $25 for a missed appointment which is not billable to your insurance.

Lab/Radiology Test Results We will only contact you if the results of your test are abnormal. We encourage you to contact our office to confirm normal results.

Messages If we are unable to reach you by phone, we will simply leave our name and number for you to return the call.

Thank you for understanding our Office and Financial Policy. Please let us know if you have any questions or concerns.

Office and Financial Policy

Welcome to my office. You probably understand if referred by your doctor to my office that this has happened with the understanding that surgery is at least one option you will have for consideration. As such I wanted to provide you with some background information as well as some expectations I have as we move forward. Please take a moment to read the following information with particular attention to the last section of our care agreement.

My Background: I was born and raised in Arizona. Following high school I attended Brigham Young University on a football scholarship and subsequently served for two years as a missionary of The Church of Jesus Christ of Latter-day Saints in Brazil, Uruguay and Paraguay. Upon my return I attended the University of Arizona earning a degree in chemistry and math. In Tucson I met my future wife and married in 1981. We have since become the parents of three bright, talented and charming children. At the University of Arizona School of Medicine, I earned my medical degree, while my wife earned her “PhT” (Push Hubby Through).

From 1987 to 1991 I trained in Obstetrics and Gynecology at the University of Nevada Affiliated Residency Training Program in Las Vegas. Upon completion of this basic training I pursued additional fellowship or postgraduate training in advanced pelvic surgery with emphasis in gynecologic oncology (cancer), pelvic reconstruction (prolapse), urological (bladder repair), colorectal (intestinal surgery) and advanced endoscopic (minimally invasive) surgery.

Upon completion I was hired by the Residency Training Program to teach residents in advanced gynecologic surgical procedures until 1995 when I left the School of Medicine for private practice. In 2000 the Residency Training Program asked me to return as the director of the Division of Gynecologic Oncology and Pelvic Reconstructive Surgery as an Associate Professor of Medicine. I continued in this capacity while continuing to see private patients for roughly three years when I returned to private practice. I have served as a consultant and instructor for U.S. Surgical Corporation and Ethicon, a division of Johnson & Johnson both major manufactures of laparoscopic instruments teaching residents in training as well as more seasoned surgeons in private and academic practices.

I hold dual board certifications by the American Board of OB/GYN and the American Association of Gynecologic Laparoscopists. My current practice consists primarily of the application of advanced surgical techniques, traditional as well as laparoscopic and robotic assisted procedures in the treatment of gynecologic cancers, urinary incontinence and prolapse procedures and even repairing fallopian tubes in an out patient setting for those who have had sterilization procedures in the past and now want more children.

How things will work: The first visit will establish the foundation for the rest of your care. You will be asked to fill out a form regarding your past medical history which we will sit down and review to familiarize me with your history. Please be complete and legible in filling out this form—I realize this request may sound a bit peculiar coming from a doctor—as it provides me with an organized mechanism to avoid missing important items in your history that could impact the quality of care I wish to provide. Please use my form without attachments.

Competence and compassionare alive and well.Notice of Privacy Practices

for Health Information (Effective 09/01/2012)

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.

If you have questions about this notice, please contact our Privacy Officer at (702) 438-4694.

OUR OBLIGATIONSWe are required by law to:• Maintain the privacy of protected health information.• Give you this notice of our legal duties and privacy

practices regarding health information about you.• Follow the terms of the notice currently in effect

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATIONDescribed as follows are the ways we may use and disclose health information that identifies you. Except for the following purposes we will use and disclose health information only with your written permission. You may revoke such permission at any time by writing to our practice’s privacy officer.

Treatment. We may use and disclose health information for your treatment and to provide you with treatment-related health care services. For example, we may disclose health information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care. We make every effort to keep your other health care providers informed of your care here in our office. In doing so, information including letters are routinely faxed to optimize the efficiency and quality of care you receive. It is possible with changes in FAX numbers or misdialing , that information may inadvertently be sent elsewhere.

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

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 of our patients receive quality care and to operate and manage our office. We also may share information with other entities that have a relationship with you ( for example, your health plan) for their health care operation activities.

Appointment Reminders, Treatment Alternatives, and Health Related Benefits and Services. We may use and disclose health information to contact you and 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-related benefits and services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share health information with a 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. If requiring surgery, it is our practice to go to the waiting room and call the name of the patient to inform family members and friends of your status and operative findings. This may allow others in the waiting room to know you are in the hospital, but not the specifics of your care.

Research. Under certain circumstances, we may use and disclose health information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another for the same condition.

SPECIAL SITUATIONSAs Required by Law. We will disclose health information when required to do so by international, federal, state, or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.

Business Associates. We may disclose health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Workers’ Compensation. We may release health information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

9. GENITOURINARY









10. MUSCULOSKELETAL


11. SKIN, BREAST




Rash: CURRENT PAST


12. PSYCHIATRIC



13. ENDOCRINE













Public Health Risks. We may disclose health information for public health activities. These activities generally include disclosures to prevent or control disease, injury, or disability; report deaths; report child abuse or neglect; report reactions to medications or problems with projects; notify people of recalls of products they may be using; inform a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and report to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example; audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information in response to a court or administrative order. We also may disclose health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release health information if asked by law enforcement officials if the information is 1) in response to a court order, subpoena, warrant, summons, or similar process; 2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; 3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; 4) about a death we believe may be the result of criminal conduct; 5) about criminal conduct on our premises; and 6) in an emergency to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

Coroners, Medical Examiners, Funeral Directors. We may release health information to a coroner, medical examiner, or funeral director as necessary for their duties. This may be necessary, for example to identify a deceased person or determine the cause of death.

Inmates or Individuals in Custody. If you are an inmate of a correctional facility or under the custody of a law enforcement official, we may release health information to the correctional facility or law enforcement official. This release would be made if necessary: 1) for the institution to provide you with health care, 2) to protect your health and safety or the health and safety of others, or 3) for the safety and security of the correctional facility.

YOUR RIGHTSYou have the following rights regarding health information we have about you. All of the following requests must be made in writing to the privacy officer.

Right to Inspect and Copy. You have a right to inspect and copy health information that may be used to make decisions about your care or payment for your care. This includes medical and billing records.

Right to Amend. If you feel that health information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by our office.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of health information for purposes other than treatment, payment, and health care operations or for which you provided written authorization.

Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. We are not required to agree with your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can request that we contact you only by mail or at work. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

CHANGES TO THIS NOTICEWe reserve the right to change this notice and make the new notice apply to health information we already have as well as any information we receive in the future.

COMPLAINTSIf you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact the privacy officer. All complaints must be made in writing. You will not be penalized for filing a complaint.

9. GENITOURINARY









10. MUSCULOSKELETAL


11. SKIN, BREAST




Rash: CURRENT PAST


12. PSYCHIATRIC



13. ENDOCRINE













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