You can elect to fill out your Patient Registration Forms on-line and submit it to our office electronically. Or you may print a blank registration form, fill it out at your convenience, and bring it with you to your appointment.
The Patient Registration Form contains the following sections:
- Patient Introduction Section
- Medical History Section
- Financial Agreement Section
- Signature Section
As stated above you may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. Please understand that the security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.
SUMMARY OF PRIVACY PRACTICES
This Summary of our Privacy Practices contains a condensed version of our Notice of Privacy Practices. Our full-length Notice is available upon request.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review if carefully.
We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your protected health information is kept private.
The following are a few examples of how we will use or disclose your information: * For Medical treatment * To obtain payment for our services * In emergencies situations * For appointment and patient recall reminders * To run our practice more efficiently and ensure that all our patients receive quality care * For worker’s compensation * In response to certain requests arising out of lawsuits or other disputes
If you believe your privacy rights have been violated, you may file a complaint with the practice or with the Secretary of Department of Health and Human Services. To file a complaint with our practice, contact our practice directly. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
You have the right regarding the information we maintain about you. These rights include:
* The right to inspect and copy your records * The right to amend * The right to an accounting of our disclosures * The right to request restrictions to disclosures * The right to a paper copy of this summary and our office Notice of Privacy Practice in its entirety * The right to request confidential communications
For more information about these rights, please see the detailed Summary of Privacy Practices that is available upon request.
For a PDF copy please visit the link below.