12
THC82P60
THC82P60
THC82P60
TEXAS HEALTH CARE, P.L.L.C.923 PENNSYLVANIA AVE.FORT WORTH, TEXAS 76104
Patient Name: _________________________________ DOB ________________________________
Referred By: __________________________________ Other Consultants: _____________________
Chief Complaint: _____________________________________________________________________
HISTORY OF PRESENT ILLNESS ALLERGIES
MEDICAL HISTORY SOCIAL HISTORY
PRIOR SURGERY OR TRAUMA HISTORY
FAMILY HISTORY
Year
Married __________________Single __________________Widowed __________________Divorced __________________Separated __________________Occupation __________________Tobacco Use: ________________Never __________________Previously, but quit ______________Packs / Year __________________Alcohol Use:Never __________________Rarely __________________Moderate __________________Daily __________________Quit __________________
Diabetes .......................Yes No _________________________High Blood Pressure ........Yes No _________________________Cancer ..........................Yes No _________________________Stroke ..........................Yes No _________________________Heart Trouble .................Yes No _________________________Arthritis / Gout ...............Yes No _________________________Lung Problems ...............Yes No _________________________Bleeding Tendency. .........Yes No _________________________Mammogram .................Yes No Date ____________________Colonoscopy ..................Yes No Date ____________________Pneumococcal Vaccine .....Yes No Date ____________________Other ............................Yes No _________________________
Diabetes .......................Yes No _________________________________________________________High Blood Pressure ........Yes No _________________________________________________________Cancer ..........................Yes No _________________________________________________________Stroke ..........................Yes No _________________________________________________________Heart Trouble .................Yes No _________________________________________________________
Patient’s Signature_________________________________________ Date ____________________
THC82P60
TEXAS HEALTH CARE, P.L.L.C.923 PENNSYLVANIA AVE.FORT WORTH, TEXAS 76104
PATIENT HISTORY/REVIEW OF SYMPTOMS ______________________________________________PATIENT NAME DOB
label space
GENITOURINARYFrequent urinationBurning or painful urinationBlood in urineChange in force or strain when urinatingIncontinence or dribblingKidney stonesEjaculation problemsNocturiaMale - Testicle PainNumber of pregnanciesNumber of miscarriagesVeneral DiseaseMUSCULOSKELETALJoint painJoint stiffness or swellingWeakness of muscles or jointsMuscle pain or crampsCold extremitiesDifficulty in walkingINTEGUMENTARY (skin/breast)Rash or itchingChange in skin colorChange in hair or nailsVaricose veinsBreast pain / lump / dischargeNEUROLOGICALFrequent or recurring headachesLight headed or dizzyConvulsions or seizuresNumbness or tingling sensationsTremorsParalysisStrokeHead injuryConvulsionsPSYCHIATRICMemory loss or confusionNervousnessDepressionInsomniaPsychosisENDOCRINEGlandular problemsHormone problemsExcessive thirstTired / SluggishDiabetesHEMTALOGIC / LYMPHATICSlow to heal after cutAnemiaPhlebitisPast blood transfusionSwollen glandsBleeding tendency
DiabetesHypertensionCancerStrokeHeart TroubleArthritis/goutAcute InfectionsCONSTITUTIONAL SYMPTOMSGood general healthRecent weight changeFeverFatigueHeadachesEYESEye disease or injuryWear glasses or contactsBlurred or double visionGlaucomaEAR/NOSE/MOUTH/THROATHearing loss or ringingEaraches or drainageChronic sinus problem or rhinitisNose bleedsMouth soresBleeding gumsBad breath or bad tasteSore throat or voice changeCleft Lip / PalateSwollen glands in neckCARDIOVASCULARHeart troubleChest pain or angina pectorisPalpitationShortness of breath with walking or lying flatSwelling of feet, ankles, or handsRESPIRATORYChronic or frequent coughsSpitting up bloodShortness of breathAsthma or wheezingGASTROINTESTINALLoss of appetiteChange in bowel movementsNausea or vomitingFrequent diarrheaPainful bowel movements or constipationRectal bleeding or blood in stoolAbdominal pain or heartburnPeptic Ulcer
HAVE YOU OR ARE YOU BEING TREATED FOR: please check or circle all that apply
Patient’s Signature ___________________________Date _________ Physician’s Initials ____ Date __________
THC82P60
DRDRDRDRDRUGUGUGUGUG PHARMAPHARMAPHARMAPHARMAPHARMACYCYCYCYCY:::::ALLERALLERALLERALLERALLERGIES:GIES:GIES:GIES:GIES:
FFFFFOODOODOODOODOOD PHARMAPHARMAPHARMAPHARMAPHARMACY PHONE NUMBER:CY PHONE NUMBER:CY PHONE NUMBER:CY PHONE NUMBER:CY PHONE NUMBER:ALLERALLERALLERALLERALLERGIES:GIES:GIES:GIES:GIES:
TEXAS HEALTH CARE, P.L.L.C.923 PENNSYLVANIA AVE.
FORT WORTH, TEXAS 76104
MEDICATION/HERB LIST
FFFFFreqreqreqreqrequencyuencyuencyuencyuencyDosageDosageDosageDosageDosageMedication/HerbMedication/HerbMedication/HerbMedication/HerbMedication/Herb
PHYSICIAN: _________________________________BEING SEEN TODAY
LOCATION: ______________ DATE: _____________
If Patient cannot be billed for these services (for example, minor children), please complete RESPONSIBLE PARTY SECTION below as wellas this patient registration information section.
Social Security #: _____________________________ Driver’s License # __________________________ State: ___________________
Name: ___________________________________________________________ ____ _____ ___ / ___ / ___ ____ ___________LAST FIRST MI SEX DATE OF BIRTH AGE MARITAL STATUS
Address: _______________________________________ __________________ ____ _______ (_____) ____________________MAILING ADDRESS APARTMENT CITY ST ZIP HOME PHONE
Alt/Cell Phone: (_____)_____________________ Day Phone: (_____)_____________________ Email: __________________________
Race__________________ Language________________________ Ethnicity Hispanic/Latin Non Hispanic/Latin
_________________________________________________ Employer’s Name: _____________________________________________EMPLOYMENT STATUS (PLEASE CIRCLE ONE) or School
Employer’s Address: _________________________________________________ ___________________ _____ _______________MAILING ADDRESS CITY ST ZIP
Occupation: __________________________________________________________________
Emergency Contact: (Please indicate a friend or relative not living at the same address.)
________________________________________________________ ______________________ (_____) _____________________NAME RELATIONSHIP EMERGENCY CONTACT #
MM DD YYS M D W O
Full-Time Part-Time Retired Unemployed Student
PATIENT REGISTRATION INFORMATION
Patient is responsible unless a minor child or guardian. RESPONSIBLE PARTY SECTION must be completed.
Patient Relationship to Responsible Party: Child____ Other ________________________ Resp. Party SS #: _____________________SPECIFY
Name: ___________________________________________________________ ____ _____ ___ / ___ / ___ ____ ___________LAST FIRST MI SEX DATE OF BIRTH AGE MARITAL STATUS
Address: _______________________________________ __________________ ____ _______ (_____) ____________________MAILING ADDRESS APARTMENT CITY ST ZIP HOME PHONE
_________________________________________________ Employer’s Name: _____________________________________________EMPLOYMENT STATUS (PLEASE CIRCLE ONE) or School
Employer’s Address: _________________________________________________ ___________________ _____ _______________MAILING ADDRESS CITY ST ZIP
Occupation: _________________________________________________________________ (_____) _______________________ (_____)WORK PHONE EXT
MM DD YYS M D W O
Full-Time Part-Time Retired Unemployed Student
RESPONSIBLE PARTY AND BILLING INFORMATION
Spouse’s Name: ___________________________________________ Employer: _____________________________________________
___ / ___ / ___ Spouse’s Work Phone: (_____) __________________ (_______) Occupation: __________________________________ DATE OF BIRTH EXT
OTHER PATIENT INFORMATION
Please complete the information below and provide a copy of the insurance card.
Insurance Company: ______________________________________ Address: __________________________ (_____) ______________STREET or P.O. BOX PHONE
Co-Pay Amount: (if applicable) ______________________________ ______________________________ _______ ______________CITY ST ZIP
Primary Care Physician: ___________________________________
Policy Holder: _____________________________________________________ ____ _____ _____/_____/_____ ______________LAST FIRST MI SEX DATE OF BIRTH SS #
Patient Relationship to Insured Party: Self___ Spouse___ Child___ Other ___________________________________________(SPECIFY)
Employer’s Name: __________________________________ ____________________________ _______________________________INSUREDS ID GROUP NAME AND/OR NUMBER
Address: ____________________________________________ __________________________ ___________ _________________STREET CITY ST ZIP
PRIMARY INSURANCE
TEXAS HEALTH CARE, P.L.L.C.923 PENNSYLVANIA AVE.
FORT WORTH, TEXAS 76104
THC82P60
Texas Health Care, P.L.L.C.923 PENNSYLVANIA AVE.
FORT WORTH, TEXAS 76104
CONSENT TO TREATBy signing this consent, I am authorizing my physician(s) and/or order another person to perform all exams, tests, procedures, injections,phlebotomy, and any other care deemed necessary or advisable for the diagnosis and treatment of my medical condition. This consentis valid for each visit I make to Dr. _________________________ , with Texas Health Care, P.L.L.C. unless revoked by me in writing.
CONSENT TO TREAT A MINOR (if applicable)This consent has been prepared according to guidelines presented by the Texas Family Code (Section 35.01). All information mustbe completed fully in this form. (Please print).
Minor’s Full Name: ___________________________________________________________________________________________
The name of one or both parents (if known) and the name of the managing conservator or guardian if either have been appointed:
__________________________________________________________________________________________________________
The name of the person giving consent and his/her relationship to the minor:
Name: _________________________________________ Relationship: __________________________________________
A statement describing the medical treatment for which consent is to be given:
__________________________________________________________________________________________________________
The following persons may consent to a minor’s medical treatment when the person having the power to consent cannot be contactedand when the absent person has not indicated a refusal to consent. Please indicate the appropriate situation as to who will be signingthe consent.
Grandparent, Adult sibling, Adult aunt or uncle, Educational institution (in which the minor is enrolled, if the person who hasthe power to consent has given the institution prior written authorization to do so), Any adult who has care and control of the minor (ifthe child’s parent or guardian has given prior authority to consent), Any court having jurisdiction of the child.
PHOTO CONSENTMedical photographs/slides and/or videotapes may be taken before, during, or after a surgical procedure or treatment. Consent isrequired to take such images. Additionally, patients may consent to release these medical photographs/slides and/or videotapes fora stated purpose.
I understand that I will not be entitled to monetary payment or any other consideration as a result of any use of these images and/or myinterview.
I (do) (do not) consent to the taking of and/or use of pre-operative, intra-operative and post-operative photographs/slides and/orvideotapes. My consent authorizes the use of these photographs/slides and/or videotapes for professional medical purposes deemedappropriate including but not limited to showing these images on public or commercial television, electronic digital networks, for purposesfor medical education, patient education, lay publication, professional publication or during lectures to medical or lay groups.
NOTICE OF PRIVACY PRACTICESI have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. Iunderstand that I am entitled to receive a copy of this document.
___________________________________________________________ __________________________________Signature of Patient or Responsible Party Date
___________________________________________________________ __________________________________Printed Name of Patient or Responsible Party Relationship to Patient
THC82P60
PAYMENT POLICYThank you for choosing Texas Health Care, the office of Dr. Yadro Ducic, Dr. Jesse Smith, Dr. Andrew Vories, Dr.Ricardo Cristobal, Amanda Hudson, RN, MSN, FNP, Lauren LeBlanc, RN, ACNP, Amy Williamson, RN, ACNP, Dr. LindiBerry, Dr. Amy Zahn, Dr. Stevie Daniel and Katrina Jensen, M.A., CCC-SLP. We are committed to providing you withquality and affordable health care. Some of our patients have had questions regarding patient and insuranceresponsibility for services rendered; due to this we have developed this payment policy. Please read it, ask us anyquestions you may have and sign in the space provided. A copy will be provided to you upon request.
1. Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we dobusiness with, payment in full is expected at each visit. If you are insured by a plan that we do business with, butdon’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage.Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questionsyou may have regarding your coverage.
2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. Thisarrangement is part of your contract with your insurance company. Failure on our part to collect co-payments anddeductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-paymentat each visit
3. Non-covered services. Please be aware that some – and perhaps all – of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services infull at the time of visit. Medicare beneficiaries are required to notify our office if enrolled in home health care or askilled nursing unit. If our office is not notified, you may be liable for services rendered.
4. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We mustobtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provideus with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.
5. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get yourclaims paid. Your insurance company may need you to supply certain information directly. It is your responsibility tocomply with their request. Please be aware that the balance of your claim is your responsibility whether or not yourinsurance pays your claim. Your insurance benefit is a contract between you and your insurance company; we arenot party to that contract.
6. Coverage changes. If your insurance changes, please notify us before your next visit so we can make theappropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claimwithin 45 days, the balance will automatically be billed to you.
7. Nonpayment. If your account balance is past due, you will receive a letter requesting that you pay your accountin full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remainsunpaid, we may refer your account to a collection agency and you may be discharged from this practice. If thisoccurs, you will be notified by regular and certified mail that you have 30 days to find alternative medical care.During that 30-day period, our physician will only be able to treat you on an emergency basis.
8. Missed appointments. Missed appointments represent a cost to us, to you and to other patients who could havebeen seen in the time set aside for you. If you are unable to keep your scheduled appointment, please give a 24-hour notice to avoid being charged. We reserve the right to charge for missed or untimely canceled appointments.Excessive abuse of scheduled appointments may result in discharge from practice.
I have read and understand the payment policy and agree to abide by it’s guidelines:
________________________________________ _____________________Signature of Patient or Responsible Party Date
Texas Health Care, P.L.L.C.923 PENNSYLVANIA AVE.
FORT WORTH, TEXAS 76104
THC82P60
THC82P60
Texas Health Care, P.L.L.C.923 PENNSYLVANIA AVE.
FORT WORTH, TEXAS 76104
AUTHORIZATION TO RELEASE HEALTH INFORMATION
Patient Name: ________________________________________________________________
Address: ____________________________________________________________________
Phone: _______________________________________ Date of Birth:__________________
My signature below gives permission for the following person(s) to pick up articles containingmy or my minor child’s personal health information such as but not limited to sample medications,correspondence, test orders, medical records, billing records, etc.
Name: _______________________________________ Relationship: __________________
Name: _______________________________________ Relationship: __________________
Name: _______________________________________ Relationship: __________________
Name: _______________________________________ Relationship: __________________
Name: _______________________________________ Relationship: __________________
This authorization is given freely with the understanding that:
1. Any and all records, whether written or oral or in electronic format, are confidential and cannot bedisclosed without my prior written authorization, except as otherwise provided by law.
2. A photocopy or fax of this authorization is as valid as this original.3. I may revoke this authorization at any time, except where information has already been released.
This authorization is valid for a one year period from the date it is signed, or sooner if notedbelow.
4. Texas Health Care, P.L.L.C. and its employees, officers, and physicians are hereby releasedfrom any legal responsibility or liability for disclosure of the above information to the extent indicatedand authorized herein.
5. Treatment, payment, enrollment or eligibility for benefits may not be conditioned upon obtainingthis Authorization.
6. Information used or disclosed pursuant to this authorization may be subject to re-disclosure bythe recipient and is no longer protected.
Signature: _____________________________________________________________
Relationship to patient: ___________________________________________________
Date: _________________________________________________________________
Texas Health Care, P.L.L.C.923 PENNSYLVANIA AVE. • FORT WORTH, TEXAS 76104
RELEASE OF INFORMATION REQUEST TO PROVIDERS
THC82P60
Patient’s Name ____________________________________________ Maiden/Former Name:_________________
Patient’s Address: _______________________________________________________________________________
City, State, Zip:_________________________________________________________________________________
Birth Date: ______________________________________________ Social Security #: ___________________
Home Phone: ____________________________________________ Other Phone:_______________________
I Authorize: To Release to:
___________________________________________ ___________________________________________
___________________________________________ ___________________________________________
___________________________________________ ___________________________________________
The following information may be released: Purpose of Disclosure:
Entire Medical Record Medical Care
Specific Record From___________to___________ Insurance
Immunizations Attorney
Billing Record Other________________________________
Only___________________________________
I consent to the release of the indicated sensitive, legally protectedrecords (patient to initial).
Mental Health Records ...................................... _____________
HIV or AIDS ..................................................... _____________
Chemical Dependency ....................................... _____________
I understand that I may revoke this consent at any time by notifying the providing organization in writing, except tothe extent that action has already been taken in reliance on it and that in any event this consent expiresautomatically in 180 days from the date of authorization.
I understand that the information disclosed under this authorization may be disclosed again by the person ororganization to which it is sent. The privacy of this information may not be protected under the federal privacyregulations.
_________________________________________________ ________________________Signature of Patient or Representative Date
_________________________________________________ ________________________Printed Name Relationship to Patient
I understand that Chemical Dependency client’s/patient’s records are protected by the Federal Law (42FR Part 2)and cannot be disclosed without this written consent unless otherwise protected.
Not
ice
of P
riva
cy P
ract
ices
This
not
ice
desc
ribe
s how
med
ical
info
rmat
ion
abou
t you
may
be
used
and
dis
clos
ed a
nd h
owyo
u ca
n ge
t acc
ess t
o th
is in
form
atio
n. P
leas
e re
view
it c
aref
ully
.Th
is pr
actic
e us
es a
nd d
isclo
ses
heal
th in
form
atio
n ab
out
you
for
trea
tmen
t, to
obt
ain
paym
ent
for
trea
tmen
t, fo
r adm
inist
rativ
e pu
rpos
es, a
nd to
eva
luat
e th
e qu
ality
of c
are
that
you
rece
ive.
This
notic
e des
crib
es ou
r priv
acy
prac
tices
. Yo
u ca
n re
ques
t a co
py of
this
notic
e at a
ny ti
me.
For
mor
ein
form
atio
n ab
out
this
notic
e or
our
priv
acy
prac
tices
and
pol
icies
, ple
ase
cont
act
the
prac
tice
team
liaiso
n in
this
offic
e.Tr
eatm
ent,
Paym
ent,
Hea
lth
Car
e O
pera
tion
sW
e ar
e pe
rmitt
ed to
use
and
disc
lose
you
r m
edica
l inf
orm
atio
n to
thos
e in
volv
ed in
you
r tr
eatm
ent.
Texa
s Hea
lth C
are,
PLLC
is a
mul
ti-sp
ecia
lty p
ract
ice a
nd w
hen
we p
rovi
de tr
eatm
ent,
we m
ay re
ques
tth
at a
ll of
you
r phy
sicia
ns sh
are y
our m
edica
l inf
orm
atio
n wi
th u
s. F
or ex
ampl
e, yo
ur ca
re m
ay re
quire
both
prim
ary c
are p
hysic
ians
and s
pecia
lty ca
re ph
ysici
ans.
Whe
n we
prov
ide t
reat
men
t, we
may
requ
est
info
rmat
ion
from
all
of y
our
phys
ician
s so
tha
t we
can
app
ropr
iate
ly t
reat
you
for
all o
ther
med
ical
cond
ition
s, if
any.
·If
your
phys
ician
is a
prim
ary c
are p
hysic
ian,
your
care
may
requ
ire th
e inv
olve
men
t of a
spec
ialis
t.W
hen
we re
fer y
ou to
a sp
ecia
list,
we w
ill sh
are s
ome o
r all
of yo
ur m
edica
l inf
orm
atio
n wi
th th
atph
ysici
an to
facil
itate
the
deliv
ery
of ca
re.
·If
your
phy
sicia
n is
a sp
ecia
list,
when
we
prov
ide
trea
tmen
t, we
may
requ
est t
hat y
our p
rimar
yca
re p
hysic
ian
shar
e you
r med
ical i
nfor
mat
ion
with
us.
Also
, we m
ay p
rovi
de y
our p
rimar
y ca
reph
ysici
an in
form
atio
n ab
out y
our p
artic
ular
cond
ition
so
that
he
or s
he ca
n ap
prop
riate
ly tr
eat
you
for o
ther
med
ical c
ondi
tions
, if a
ny.
·If
your
tre
atm
ent
has
been
ord
ered
by
your
phy
sicia
n, b
ut is
bei
ng p
rovi
ded
by a
n an
cilla
ryde
part
men
t, su
ch as
any t
hera
pies
, we a
re pe
rmitt
ed to
use
and d
isclo
se yo
ur m
edica
l inf
orm
atio
nto
tho
se in
volv
ed in
you
r tr
eatm
ent.
Whe
n we
pro
vide
tre
atm
ent,
we m
ay r
eque
st t
hat
your
phys
icia
n sh
are
your
med
ical
info
rmat
ion
with
us.
Als
o, w
e m
ay p
rovi
de y
our
phys
icia
nin
form
atio
n ab
out
your
par
ticul
ar c
ondi
tion
so t
hat
he o
r sh
e ca
n ap
prop
riate
ly t
reat
you
for
othe
r med
ical c
ondi
tions
, if a
ny.
Paym
ent
We
are
perm
itted
to
use
and
disc
lose
you
r m
edica
l inf
orm
atio
n to
bill
and
col
lect
pay
men
t fo
r th
ese
rvice
s pr
ovid
ed to
you
. Fo
r ex
ampl
e, we
may
com
plet
e a
claim
form
to o
btai
n pa
ymen
t fro
m y
our
insu
rer
or H
MO.
T
he fo
rm w
ill c
onta
in m
edica
l inf
orm
atio
n, s
uch
as a
des
crip
tion
of t
he m
edica
lse
rvice
pro
vide
d to
you
, tha
t you
r ins
urer
or H
MO
need
s to
appr
ove
paym
ent t
o us
.H
ealt
h C
are
Ope
rati
ons
We a
re p
erm
itted
to u
se or
disc
lose
you
r med
ical i
nfor
mat
ion
for t
he p
urpo
ses o
f hea
lth ca
re op
erat
ions
,wh
ich a
re a
ctiv
ities
that
supp
ort t
his p
ract
ice a
nd e
nsur
e th
at q
ualit
y ca
re is
del
iver
edFo
r ex
ampl
e, we
may
ask
ano
ther
phy
sicia
n to
rev
iew
this
prac
tice’s
cha
rts
and
med
ical r
ecor
ds t
oev
alua
te o
ur p
erfo
rman
ce s
o th
at w
e m
ay e
nsur
e th
at o
nly
the
best
hea
lth c
are
is pr
ovid
ed b
y th
ispr
actic
e.D
iscl
osur
es T
hat C
an B
e M
ade
Wit
hout
You
r Au
thor
izat
ion
Ther
e ar
e sit
uatio
ns in
whi
ch w
e ar
e pe
rmitt
ed b
y la
w to
disc
lose
or
use
your
med
ical i
nfor
mat
ion
with
out y
our w
ritte
n au
thor
izatio
n or
an
oppo
rtun
ity to
objec
t. In
othe
r situ
atio
ns w
e will
ask
for y
our
writt
en a
utho
rizat
ion
befo
re u
sing
or d
isclo
sing
any
iden
tifia
ble
heal
th in
form
atio
n ab
out y
ou.
If yo
uch
oose
to
sign
an a
utho
rizat
ion
to d
isclo
se in
form
atio
n, y
ou c
an la
ter
revo
ke t
hat
auth
oriz
atio
n, in
writi
ng, t
o st
op fu
ture
use
s an
d di
sclo
sure
s. H
owev
er, a
ny re
voca
tion
will
not a
pply
to d
isclo
sure
s or
uses
alre
ady
mad
e or
take
n in
relia
nce
on th
at a
utho
rizat
ion.
Publ
ic H
ealt
h, A
buse
or
Neg
lect
, and
Hea
lth
Ove
rsig
htW
e m
ay d
isclo
se y
our
med
ical i
nfor
mat
ion
for
publ
ic he
alth
act
iviti
es.
Publ
ic he
alth
act
iviti
es a
rem
anda
ted
by fe
dera
l, st
ate,
or lo
cal g
over
nmen
t for
the
colle
ctio
n of
info
rmat
ion
abou
t dise
ase,
vita
lst
atist
ics (l
ike
birt
hs a
nd d
eath
), or
inju
ry b
y a
publ
ic he
alth
aut
horit
y.
We
may
disc
lose
med
ical
info
rmat
ion,
if a
utho
rized
by
law,
to a
per
son
who m
ay h
ave b
een
expo
sed
to a
dise
ase o
r may
be a
t risk
for c
ontr
actin
g or
spre
adin
g a
dise
ase o
r con
ditio
n. W
e may
disc
lose
you
r med
ical i
nfor
mat
ion
to re
port
reac
tions
to m
edica
tions
, pro
blem
s with
pro
duct
s, or
to n
otify
peo
ple
of re
calls
of p
rodu
cts t
hey
may
be
usin
g.
We m
ay a
lso d
isclo
se m
edica
l inf
orm
atio
n to
a p
ublic
age
ncy
auth
orize
d to
rece
ive r
epor
ts of
child
abu
seor
neg
lect
. Te
xas l
aw re
quire
s phy
sicia
ns to
repo
rt ch
ild a
buse
or n
egle
ct. R
egul
atio
ns a
lso p
erm
it th
edi
sclo
sure
of i
nfor
mat
ion
to re
port
abu
se o
r neg
lect
of e
lder
s or t
he d
isabl
ed.
We
may
disc
lose
you
r med
ical i
nfor
mat
ion
to a
hea
lth o
vers
ight
age
ncy
for t
hose
act
iviti
es a
utho
rized
by la
w. E
xam
ples
of t
hese
act
iviti
es a
re a
udits
, inv
estig
atio
ns, l
icens
ure
appl
icatio
ns a
nd in
spec
tions
which
are a
ll go
vern
men
t act
iviti
es u
nder
take
n to
mon
itor t
he h
ealth
care
deliv
ery s
yste
m an
d com
plia
nce
with
oth
er la
ws, s
uch
as ci
vil r
ight
s law
s.Le
gal P
roce
edin
gs a
nd L
aw E
nfor
cem
ent
We
may
disc
lose
you
r m
edica
l inf
orm
atio
n in
the
cou
rse
of ju
dicia
l or
adm
inist
rativ
e pr
ocee
ding
s in
resp
onse
to
an o
rder
of t
he c
ourt
(or
the
adm
inist
rativ
e de
cisio
n-m
aker
) or
othe
r ap
prop
riate
lega
lpr
oces
s. C
erta
in re
quire
men
ts m
ust b
e m
et b
efor
e th
e in
form
atio
n is
disc
lose
d.If
aske
d by
a la
w en
forc
emen
t of
ficia
l, we
may
dis
clos
e yo
ur m
edic
al in
form
atio
n un
der
limite
dcir
cum
stan
ces
prov
ided
that
the
info
rmat
ion:
·Is
rele
ased
pur
suan
t to
lega
l pro
cess
, suc
h as
a w
arra
nt o
r sub
poen
a;·
Pert
ains
to a
vict
im o
f crim
e an
d yo
ur a
re in
capa
citat
ed;
·Pe
rtai
ns to
a p
erso
n wh
o ha
s die
d un
der c
ircum
stan
ces t
hat m
ay b
e re
late
d to
crim
inal
cond
uct;
·Is
abo
ut a
vict
im o
f crim
e an
d we
are
una
ble
to o
btai
n th
e pe
rson
’s ag
reem
ent;
·Is
rele
ased
bec
ause
of a
crim
e th
at h
as o
ccur
red
on th
ese
prem
ises;
or·
Is re
leas
ed to
loca
te a
fugi
tive,
miss
ing
pers
on, o
r sus
pect
.W
e may
also
rele
ase i
nfor
mat
ion
if we
belie
ve th
e disc
losu
re is
nec
essa
ry to
prev
ent o
r les
sen
an im
min
ent
thre
at to
the
heal
th o
r saf
ety
of a
per
son.
Wor
kers
’ Com
pens
atio
nW
e m
ay d
isclo
se y
our m
edica
l inf
orm
atio
n as
requ
ired
by th
e Te
xas w
orke
rs’ c
ompe
nsat
ion
law.
Inm
ates
If yo
u ar
e an
inm
ate o
r und
er th
e cus
tody
of la
w en
forc
emen
t, we
may
rele
ase y
our m
edica
l inf
orm
atio
nto
the c
orre
ctio
nal i
nstit
utio
n or
law
enfo
rcem
ent o
fficia
l. Th
is re
leas
e is p
erm
itted
to al
low
the i
nstit
utio
nto
pro
vide
you
with
med
ical c
are,
to p
rote
ct y
our
heal
th o
r th
e he
alth
and
saf
ety
of o
ther
s, or
for
the
safe
ty a
nd s
ecur
ity o
f the
inst
itutio
n.M
ilita
ry, N
atio
nal S
ecur
ity
and
Inte
llige
nce
Acti
viti
es, P
rote
ctio
n of
the
Pres
iden
tW
e may
disc
lose
you
r med
ical i
nfor
mat
ion
for s
pecia
lized
gov
ernm
enta
l fun
ctio
ns su
ch a
s sep
arat
ion
ordi
scha
rge f
rom
mili
tary
serv
ice, r
eque
sts a
s nec
essa
ry b
y ap
prop
riate
mili
tary
com
man
d of
ficer
s (if
you
are i
n th
e mili
tary
), au
thor
ized n
atio
nal s
ecur
ity an
d int
ellig
ence
activ
ities
, as w
ell a
s aut
horiz
ed ac
tiviti
esfo
r the
prov
ision
of pr
otec
tive s
ervi
ces f
or th
e Pre
siden
t of t
he U
nite
d Sta
tes,
othe
r aut
horiz
ed go
vern
men
tof
ficia
ls, o
r for
eign
hea
ds o
f sta
te.
Res
earc
h, O
rgan
Don
atio
n, C
oron
ers,
Med
ical
Exa
min
ers,
and
Fun
eral
Dir
ecto
rsW
hen
a re
sear
ch p
rojec
t an
d its
priv
acy
prot
ectio
ns h
ave
been
app
rove
d by
an
Inst
itutio
nal R
evie
wBo
ard
or p
rivac
y bo
ard,
we
may
rele
ase
med
ical i
nfor
mat
ion
to re
sear
cher
s for
rese
arch
pur
pose
s. W
em
ay r
elea
se m
edica
l inf
orm
atio
n to
org
an p
rocu
rem
ent
orga
niza
tions
for
the
purp
ose
of fa
cilita
ting
orga
n, e
ye, o
r tiss
ue d
onat
ion
if yo
u ar
e a
dono
r. A
lso, w
e m
ay re
leas
e yo
ur m
edica
l inf
orm
atio
n to
aco
rone
r or m
edica
l exa
min
er to
iden
tify
a de
ceas
ed o
r a ca
use
of d
eath
. Fu
rthe
r, we
may
rele
ase
your
med
ical i
nfor
mat
ion
to a
fune
ral d
irect
or w
here
such
a d
isclo
sure
is n
eces
sary
for t
he d
irect
or to
carr
you
t his
dutie
s.R
equi
red
by L
awW
e m
ay re
leas
e yo
ur m
edica
l inf
orm
atio
n wh
ere
the
disc
losu
re is
requ
ired
by la
w.O
ther
use
s an
d D
iscl
osur
esW
e wi
ll no
t use
or s
ell y
our p
rote
cted
hea
lth in
form
atio
n fo
r mar
ketin
g or
any
oth
er p
urpo
ses w
ithou
tyo
ur e
xpre
ssed
per
miss
ion.
Your
Rig
hts
Und
er F
eder
al P
riva
cy R
egul
atio
nsTh
e U
nite
d St
ates
Dep
artm
ent o
f Hea
lth a
nd H
uman
Ser
vice
s cre
ated
regu
latio
ns in
tend
ed to
pro
tect
patie
nt p
rivac
y as r
equi
red
by th
e Hea
lth In
sura
nce P
orta
bilit
y and
Acc
ount
abili
ty A
ct (H
IPAA
). T
hose
regu
latio
ns cr
eate
seve
ral p
rivile
ges t
hat p
atie
nts m
ay ex
ercis
e. W
e will
not
reta
liate
aga
inst
a p
atie
ntth
at e
xerc
ises
thei
r HIP
AA ri
ghts
.TH
C99
P92
Req
uest
ed R
estr
icti
ons
You
may
requ
est t
hat w
e res
trict
or li
mit
how
your
pro
tect
ed h
ealth
info
rmat
ion
is us
ed or
disc
lose
d fo
rtr
eatm
ent,
paym
ent,
or h
ealth
care
ope
ratio
ns.
·If
you
have
hea
lth in
sura
nce c
over
age a
nd pe
rson
ally
pay,
out-o
f-poc
ket,
in fu
ll fo
r med
ical s
ervi
ces
prov
ided
, you
may
requ
est t
hat w
e no
t sub
mit
any
info
rmat
ion
rega
rdin
g th
ese
serv
ices t
o yo
urin
sura
nce
carr
ier.
·To
req
uest
this
rest
rictio
n, n
otify
the
front
des
k of
the
phys
ician
’s of
fice.
You
will
be
prov
ided
with
a se
para
te fo
rm d
ocum
entin
g th
is re
ques
t. P
leas
e gi
ve o
r sen
d th
e re
ques
t to
the
Prac
tice
Team
Lia
ison
in th
is of
fice.
You
may
also
req
uest
tha
t we
lim
it di
sclo
sure
to
fam
ily m
embe
rs, o
ther
rel
ativ
es, o
r clo
se p
erso
nal
frien
ds th
at m
ay o
r may
not
be
invo
lved
in y
our c
are.
Rec
eivi
ng C
onfid
enti
al C
omm
unic
atio
ns b
y Al
tern
ativ
e M
eans
You
may
requ
est t
hat w
e sen
d co
mm
unica
tions
of p
rote
cted
hea
lth in
form
atio
n by
alte
rnat
ive m
eans
orto
an
alte
rnat
ive
loca
tion.
Thi
s re
ques
t mus
t be
mad
e in
writ
ing
to th
e pe
rson
list
ed b
elow
. W
e ar
ere
quire
d to
acc
omm
odat
e on
ly re
ason
able
requ
ests
. Pl
ease
spec
ify in
you
r cor
resp
onde
nce
exac
tly h
owyo
u wa
nt u
s to
com
mun
icate
with
you
and
, if y
ou a
re d
irect
ing
us to
sen
d it
to a
par
ticul
ar p
lace
, the
cont
act/a
ddre
ss in
form
atio
n.In
spec
tion
and
Cop
ies
of P
rote
cted
Hea
lth
Info
rmat
ion
You
may
insp
ect
and/
or c
opy
heal
th in
form
atio
n th
at is
with
in t
he d
esig
nate
d re
cord
set
, whi
ch is
info
rmat
ion
that
is u
sed
to m
ake d
ecisi
ons a
bout
you
r car
e. T
exas
law
requ
ires t
hat r
eque
sts f
or co
pies
be m
ade
in w
ritin
g an
d we
ask
that
requ
ests
for i
nspe
ctio
n of
you
r hea
lth in
form
atio
n al
so b
e m
ade
inwr
iting
. Pl
ease
send
you
r req
uest
to th
e pe
rson
list
ed b
elow
.W
e can
refu
se to
pro
vide
som
e of t
he in
form
atio
n yo
u as
k to
insp
ect o
r ask
to be
copi
ed if
the i
nfor
mat
ion:
·In
clude
s ps
ycho
ther
apy
note
s.·
Inclu
des
the
iden
tity
of a
per
son
who
prov
ided
info
rmat
ion
if it
was
obta
ined
und
er a
pro
mise
of
conf
iden
tialit
y.·
Is su
bjec
t to
the
Clin
ical L
abor
ator
y Im
prov
emen
ts A
men
dmen
ts o
f 198
8.·
Has
bee
n co
mpi
led
in a
ntici
patio
n of
litig
atio
n.W
e ca
n re
fuse
to p
rovi
de a
cces
s to
or
copi
es o
f som
e in
form
atio
n fo
r ot
her
reas
ons,
prov
ided
that
we
prov
ide
a re
view
of o
ur d
ecisi
on o
n yo
ur r
eque
st.
Anot
her
licen
sed
heal
th c
are
prov
ider
who
was
not
invo
lved
in th
e pr
ior d
ecisi
on to
den
y ac
cess
will
mak
e an
y su
ch re
view
.Te
xas l
aw re
quire
s tha
t we a
re re
ady t
o pro
vide
copi
es or
a na
rrat
ive w
ithin
15 d
ays o
f you
r req
uest
. We
will
info
rm y
ou o
f whe
n th
e re
cord
s ar
e re
ady
or if
we
belie
ve a
cces
s sh
ould
be
limite
d.
If we
den
yac
cess
, we
will
info
rm y
ou in
writ
ing.
HIP
AA p
erm
its u
s to c
harg
e a re
ason
able
cost
bas
ed fe
e. T
he T
exas
Sta
te B
oard
of M
edica
l Exa
min
ers
(TSB
ME)
has
set
lim
its o
n fe
es fo
r co
pies
of m
edica
l rec
ords
that
und
er s
ome
circu
mst
ance
s m
ay b
elo
wer t
han
the c
harg
es p
erm
itted
by
HIP
AA.
In a
ny ev
ent,
the l
ower
of th
e fee
per
mitt
ed b
y H
IPAA
orth
e fe
e pe
rmitt
ed b
y th
e TS
BME
will
be ch
arge
d.Am
endm
ent o
f Med
ical
Inf
orm
atio
nYo
u m
ay r
eque
st a
n am
endm
ent o
f you
r m
edica
l inf
orm
atio
n in
the
desig
nate
d re
cord
set
. An
y su
chre
ques
t mus
t be
mad
e in
writ
ing
to th
e pe
rson
list
ed b
elow
. W
e wi
ll re
spon
d wi
thin
60
days
of y
our
requ
est.
We
may
refu
se to
allo
w an
am
endm
ent i
f the
info
rmat
ion:
·W
asn’
t cre
ated
by
this
prac
tice
or th
e ph
ysici
ans h
ere
in th
is pr
actic
e.·
Is n
ot p
art o
f the
Des
igna
ted
Reco
rd S
et?
·Is
not
ava
ilabl
e fo
r ins
pect
ion
beca
use
of a
n ap
prop
riate
den
ial.
·If
the
info
rmat
ion
is ac
cura
te a
nd co
mpl
ete.
Even
if w
e re
fuse
to a
llow
an a
men
dmen
t you
are
per
mitt
ed to
inclu
de a
pat
ient
sta
tem
ent a
bout
the
info
rmat
ion
at is
sue i
n yo
ur m
edica
l rec
ord.
If w
e ref
use t
o allo
w an
am
endm
ent w
e will
info
rm y
ou in
writi
ng.
If we
app
rove
the a
men
dmen
t, we
will
info
rm y
ou in
writ
ing,
allo
w th
e am
endm
ent t
o be m
ade
and
tell
othe
rs th
at w
e kn
ow h
ave
the
inco
rrec
t inf
orm
atio
n.Ac
coun
ting
of C
erta
in D
iscl
osur
esTh
e H
IPAA
priv
acy
regu
latio
ns p
erm
it yo
u to
requ
est,
and
us to
pro
vide
, an
acco
untin
g of
disc
losu
res
that
are
othe
r tha
n fo
r tre
atm
ent,
paym
ent,
heal
th ca
re op
erat
ions
, or m
ade v
ia a
n au
thor
izatio
n sig
ned
by y
ou o
r you
r rep
rese
ntat
ive.
Ple
ase
subm
it an
y re
ques
t for
an
acco
untin
g to
the
pers
on li
sted
bel
ow.
Your
firs
t acc
ount
ing
of d
isclo
sure
s (w
ithin
a 1
2 m
onth
per
iod)
will
be
free.
For
add
ition
al r
eque
sts
with
in th
at p
erio
d we
are
per
mitt
ed to
char
ge fo
r the
cost
of p
rovi
ding
the
list.
If th
ere
is a
char
ge w
ewi
ll no
tify
you
and
you
may
choo
se to
with
draw
or m
odify
you
r req
uest
bef
ore a
ny co
sts a
re in
curr
ed.
Appo
intm
ent R
emin
ders
, Tre
atm
ent A
lter
nati
ves,
and
Oth
er H
ealt
h-re
late
d B
enef
its
We
may
cont
act y
ou b
y te
leph
one,
mai
l, or
bot
h to
pro
vide
app
oint
men
t rem
inde
rs, i
nfor
mat
ion
abou
ttr
eatm
ent a
ltern
ativ
es, o
r oth
er h
ealth
-rela
ted
bene
fits a
nd se
rvice
s tha
t may
be
of in
tere
st to
you
.C
ompl
aint
sIf
you
are
conc
erne
d th
at y
our p
rivac
y rig
hts h
ave
been
vio
late
d, y
ou m
ay co
ntac
t our
Priv
acy
Offic
er.
You
may
also
send
a wr
itten
com
plai
nt to
the U
nite
d St
ates
Dep
artm
ent o
f Hea
lth an
d H
uman
Ser
vice
s.W
e will
not
reta
liate
agai
nst y
ou fo
r fili
ng a
com
plai
nt w
ith th
e gov
ernm
ent o
r us.
The c
onta
ct in
form
atio
nfo
r the
Uni
ted
Stat
es D
epar
tmen
t of H
ealth
and
Hum
an S
ervi
ces i
s:U
.S. D
epar
tmen
t of H
ealth
and
Hum
an S
ervi
ces
HIP
AA C
ompl
aint
7500
Sec
urity
Blv
d., C
5-24
-04
Balti
mor
e, M
D 21
244
Our
Pro
mis
e to
You
We a
re re
quire
d by
law
and
regu
latio
n to
pro
tect
the p
rivac
y of y
our m
edica
l inf
orm
atio
n, to
pro
vide
you
with
this
notic
e of
our
priv
acy
prac
tices
with
resp
ect t
o pr
otec
ted
heal
th in
form
atio
n, a
nd to
abi
de b
yth
e te
rms o
f the
not
ice o
f priv
acy
prac
tices
in e
ffect
.Q
uest
ions
and
Con
tact
Per
son
for
Req
uest
sIf
you
have
any
que
stio
ns o
r wa
nt to
mak
e a
requ
est p
ursu
ant t
o th
e rig
hts
desc
ribed
abo
ve, p
leas
eco
ntac
t:L.
Tim
othy
Knu
tson
, Priv
acy
Offic
erTe
xas
Hea
lth C
are
2821
Lac
klan
d Ro
ad, S
uite
300
Fort
Wor
th, T
X 7
6116
(817
) 740
-840
0tk
nuts
on@t
xhea
lthca
re.co
m
This
notic
e is
effe
ctiv
e on
the
follo
wing
dat
e: M
arch
1, 2
013.
We
may
chan
ge o
ur p
olici
es a
nd th
is no
tice
at a
ny ti
me
and
have
thos
e re
vise
d po
licie
s app
ly to
all
the
prot
ecte
d he
alth
info
rmat
ion
we m
aint
ain.
If o
r whe
n we
chan
ge ou
r not
ice, w
e will
pos
t the
new
not
icein
the
offic
e wh
ere
it ca
n be
seen
. Ackn
owle
dgem
ent o
f Rev
iew
of
Not
ice
of P
riva
cy P
ract
ices
I hav
e re
view
ed th
is of
fice’s
Not
ice o
f Priv
acy
Prac
tices
, whi
ch e
xpla
ins
how
my
med
ical i
nfor
mat
ion
will
be u
sed
and
disc
lose
d. I
und
erst
and
that
I am
ent
itled
to re
ceiv
e a
copy
of t
his d
ocum
ent.
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atur
e of
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ient
or P
erso
nal R
epre
sent
ativ
e
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e of
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ient
or P
erso
nal R
epre
sent
ativ
e
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Desc
riptio
n of
Per
sona
l Rep
rese
ntat
ive’s
Aut
horit
y
