PEAK ORTHOPEDICS & SPINE P ATI E NT INFO R MATION Patient Name _ ___ _ ________ _ _ ______ ________ __ _ Last First M.l. Address --------------------------------- Street Address _ __________________ _ __ E mai l ___________ _ City State ZIP Code Phon e # ____ ____ _ _ W o r k # ______ _ _ _ C e l l# _________ _ Date o f Birth _ _ _ / _ __ / ___ Ag e _ _ _ Gender MI F SSN _ _ _ Em p l oye r ________________ _ Ad dres s ___ _ ________ _ Primar y Ca re Physi c ia n _________ ____ Phone # _________ ___ _ RESPONSIBLE PARTY ( on e who c ar r ies insuranc e ) N a m e _____________ ___ _ _ Re l at i onshi p t o Patie n t ________ _ Da te of Birth / / SSN ------------------ ---- Addres s _ _ ___ __ __ _ C ity _ ___ _ ____ S tate ___ Zi p C o d e _ __ _ Pho n e # _ __ _ _ __ __ Work# _ _ _ _ _ __ Empl oye r _________ _ INSUCE INFORMATION Pri m ary Ins. _ ___ _ _____ _ I D # _____ Gr oup# _ ____ Co p ay$ ___ _ Seconda ry Ins. _ _ _ __ _ ___ _ ID # Gr ou p # Copay$ __ _ EMERGENCY CONTACT (re l ativ e or fri e nd n ot li v in g w ith yo u ) Name Pho ne # ------------------ -------------- I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO PHYSICIAN OR SUPPLIER FOR THESE SERVICES AND ALL FUTURE CLAIMS. I UNDERSTAND THAT I AM RESPONSIBLE FOR Y AMOUNT NOT COVERED BY INSURANCE AND IT IS MY RESPONSIBILTIY TO KNOW MY COPAYS, DEDUCTIBLES, OUT-OF-POCKET AMOUNTS, ETC. WHICH HAVE BEEN ESTABLISHED THROUGH MY INDIVIDUAL INSURANCE POLICY. I AUTHORIZE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM AND ALL FUTURE CLAIMS. Sig nature ___________________ _ _ _ Date __ _ _____ _
Transcript
PEAK ORTHOPEDICS & SPINE
PATIENT INFORMATION
Patient Name _______________________________ _ Last First M.l.
Address ---------------------------------
Street Address
______________________ Email ___________ _ City State ZIP Code
Other Medical Conditions: ! ----------'----..l.---l..--------------------'----_;_ _
_
__J
[ Social His�: ---------------------------------------�
Do You Smoke? Yes or No If yes, how many years? ___ Number of packs per day? __ _ -------------------------------------------
Have you quit smoking? Yes or No
Do you drink alcohol? Yes or No
Year Quit ___ _
If yes, Amount ____ Monthly Weekly Daily --------------------------------------------�
History of Drug Abuse? Yes or No History of Alcohol Abuse? Yes or No 1----- --- - ---------------------------------------------l
Do you currently use recreational drug? Yes or No
Reviewing HSC RN N/ A HSC Anesthesiologist NI A L.--------------------------------
Date: Date:
Peak Orthopedics & Spine, PLLC Notice of Privacy Practices for Protected Health Information
9777 S. Yosemite Street, Suite 220
Lone Tree, CO 80124
Phone: 303-699-7325
Fax: 303-699-5486
www.oeakorthooedics.com
Your Information. Your Rights. Our Responsibilities.
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.
Our Uses and
Disclosures
You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we've sharedyour information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacyrights have been violated
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers' compensation, law enforcement.and other government requests
• Respond to lawsuits and legal actions
Notice of Privacy Practices • Page 1
► See page 2 for
more information on
these rights and how
to exercise them
► See page 3 for
more information on
these choices and
how to exercise them
► See pages 3 and 4
for more information
on these uses and
disclosures
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
Ask us to correct your medical record
Request confidential communications
Ask us to limit what we use or share
Get a list of those with whom we've shared information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint if you feel your rights are violated
• You can ask to see or get an electronic or paper copy of your medical record andother health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
• You can ask us to correct health information about you that you think is incorrector incomplete. Ask us how to do this.
• We may say "no" to your request, but we'll tell you why in writing within 60 days.
• You can ask us to contact you in a specific way (for example, home or office phone)or to send mail to a different address.
• We will say "yes" to all reasonable requests.
• You can ask us not to use or share certain health information for treatment,payment, or our operations. We are not required to agree to your request, and wemay say "no" if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not toshare that information for the purpose of payment or our operations with your healthinsurer. We will say "yes" unless a law requires us to share that information.
• You can ask for a list (accounting) of the times we've shared your health informationfor six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, andhealth care operations, and certain other disclosures (such as any you asked us tomake). We'll provide one accounting a year for free but will charge a reasonable,cost-based fee if you ask for another one within 12 months.
• You can ask for a paper copy of this notice at any time, even if you have agreed toreceive the notice electronically. We will provide you with a paper copy promptly.
• If you have given someone medical power of attorney or if someone is your legalguardian, that person can exercise your rights and make choices about your healthinformation.
• We will make sure the person has this authority and can act for you before we takeany action.
• You can complain if you feel we have violated your rights by contacting us using theinformation on page 1.
• You can file a complaint with the U.S. Department of Health and Human ServicesOffice for Civil Rights by sending a letter to 200 Independence Avenue, S.W.,Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
