Cardiology assoc - forms console.xls

Cardiology Associates
Acknowledgement of Receipt of Notice of Privacy Practices
I, __________________________________________, acknowledge that I have received a copy of Cardiology Associates' Notice of Privacy Practices. This Notice describes how Cardiololgy Associates may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health (Signature of Patient or Personal Representative) Cardiology Associates
Allergies:
REASON FOR VISIT:
HPI:
Risk Factors:
Social Hx:
Family Hx: ______________
Comments/Other
Past Medical History: circle if positive
PAST CARDIAC HISTORY
Past cardiac surgeries
Gal bladder dz Past cardiac procedures
Past cardiac testing
Past Surgical History list any surgery, date of, or problems w/ anesthesia
Comments/other
Medications:
BP HR R WT BMI Home BP's Daily wt's
o wel developed o il appearing o cachectic o obese Cardiac:_______________________________________________
______________________________________________________
Eyes: conjunctiva and lids
Vascular: radial____________femoral___________Pedal_______
ENMT: teeth gums palate
MS: gait normal o yes /abn_________________________
Neck: Jugular viens
Kyphosis/scoliosis o no /abn_________________________ Skin: xanthoma o no Turgor good/poor
Resp: Effort
Neuro: AOxIII o yes /abn_______________________
affect flat/appropriate/anxious________________________ GI: tenderness/masses
EKG: __________________________________________________
Labs/date ________; bun creat LDL HDL TC TRI K
Assessment:
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW CARDIOLOGY ASSOCIATES MAY USE AND DISCLOSE YOUR HEALTHCARE INFORMATION AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Cardiology Associates is required by law to maintain the privacy of your protected health information. This information consists of al records related to yourhealth, including demographic information, either created by Cardiology Associates or received by Cardiology Associates from other healthcare providers.
We are required to provide you with notice of our legal duties and privacy practices with respect to your protected health information. These legal duties andprivacy practices are described in this Notice. Cardiology Associates wil abide by the terms of this Notice, or the Notice currently in effect at the time of theuse or disclosure of your protected health information.1Cardiology Associates reserves the right to change the terms of this Notice and to make any new provisions effective for al protected health information thatwe maintain. Patients wil be provided a copy of any revised Notices upon request. An individual may obtain a copy of the current Notice from our office at anytime.
Uses and Disclosures of Your Protected Health Information not Requiring Your Consent Cardiology Associates may use and disclose your protected health information, without your written consent or authorization, for certain treatment, paymentand healthcare operations. There are certain restrictions on uses and disclosures of treatment records, which include registration and al other recordsconcerning individuals who are receiving, or who at any time have received services for mental il ness, developmental disabilities, alcoholism, or drugdependence. There are also restrictions on disclosing HIV test results.
Providing, coordinating, or managing healthcare and related services by one or more healthcare providers; Consultations between healthcare providers concerning a patient; Referrals to other providers for treatment; Referrals to nursing homes, foster care homes, or home health agencies.
For example, Cardiology Associates may determine that you require the services of a specialist. In referring you to another doctor, Cardiology Associates may share or transfer your healthcare information to that doctor.
Activities undertaken by Cardiology Associates to obtain reimbursement for services provided to you; Determining your eligibility for benefits or health insurance coverage; Managing claims and contacting your insurance company regarding payment; Col ection activities to obtain payment for services provided to you;Reviewing healthcare services and discussing with your insurance company the medical necessity of certain services or procedures, coverageunder your health plan, appropriateness of care, or justification of charges;Obtaining pre-certification and pre-authorization of services to be provided to you.
For example, Cardiology Associates wil submit claims to your insurance company on your behalf. This claim identifies you, your diagnosis, and theservices provided to you.
Contacting healthcare providers and patients with information about treatment alternatives; Conducting quality assessment and improvement activities; Conducting outcomes evaluation and development of clinical guidelines; Protocol development, case management, or care coordination; Conducting or arranging for medical review, legal services, and auditing functions.
For example, Cardiology Associates may use your diagnosis, treatment, and outcome information to measure the quality of the services that weprovide, or assess the effectiveness of your treatment when compared to patients in similar situations.
Cardiology Associates may contact you, by telephone or mail, to provide appointment reminders. You must notify us if you do not wish to receive appointmentreminders.
We may not disclose your protected health information to family members or friends who may be involved with your treatment or care without your writtenpermission. Health informmation may be released without written permission to a parent, guardian, or legal custodian of a child; the guardian of anincompetent adult; the healthcare agent designated in an incapacitated patient's healthcare power of attorney; or the personal representative or spouse of adeceased patient.
There are additional situation when Cardiology Associates is permitted or required to use or disclose your protected health information without your consent orauthorization. Examples include the fol owing: In certain circumstances we may be required to report individual health information to legal authorities, such as law enforcement officials, court officials,or government agencies. For example, we may have to report abuse, neglect, domestic violence or certain physicial injuries. We are required to reportgunshot wounds or any other wound to law enforcement officials if there is reasonable cause to believe that the wound occurred as a result of a crime.
Mental health records may be disclosed to law enforcement authorities for the purpose of reporting an apparent crime on our premises.
For public health activities.
We may release healthcare records, with the exception of treatment records, to certain government agencies or public health authority authorized bylaw, upon receipt of written request from that agency. We are required to report positive HIV test results to the state epidemiologist. We may alsodisclose HIV test results to other providers or persons when there has been or wil be risk of exposure.
1This Notice is prepared in accordance with the Health Insurance Portability and Accountability Act, 45 C.F.R. 164.520.
We may report to te state epidemiologist the name of any person known to have been significantly exposed to a patient who tests positive for HIV. Weare required by law to report suspected child abuse and neglect and suspected abuse of an unborn child, but cannot disclose HIV test results inconnection with the reporting or prosecution of al eged abuse or neglect. We may release healthcare records, including treatment records and HIV testresults, to the Food and Drug Administration when required by federal law. We may disclose healthcare records, except for HIV test results, for thepurpose of reporting elder abuse or neglect, provided the subject of the abuse or neglect agrees, or if necessary to prevent serious harm. Records maybe released for the reporting of domestic violence if necessary to protect the patient or community from imminent and substantial danger.
For health oversight activities.
We may disclose healthcare records, including treatment records, in response to a written request by any federal or state governmental agency toperform legal y authorized functions, such as management audits, financial audits, program monitoring and evaluation, and facility or individuallicensure or certification. HIV test results may not be released to federal or state governmental agencies, without written permission, except to the stateepidemiologist for surveil ance, investigation, or to control communicable diseases.
Judicial and Administrative Proceedings.
Patient healthcare records, including treatment records and HIV test results, may be disclosed pursuant to a lawful court order. A suboena signed by ajudge is sufficient to permit disclosure of al healthcare records except for HIV test results.
For activities related to death.
We may disclose patient healthcare records, except for treatment records, to a corner or medical examiner for the purpose of completing a medicalcertificate or investigating a death. HIV test results may be disclosed under certain circumstances.
Under certain circumstances, and only after a special approval process, we may use and disclose your health information to help conduct research.
To avoid a serious threat to health or safety.
We may report a patient's name and other relevant data to the Department of Transportation if it is believevd the patient's vision or physical or mentalcondition affects the patient's ability to exercise reasonable or ordinary control over a motor vehicle. Healthcare information, including treatment recordsand HIV test results, may be disclosed where disclosure is necessary to protect the patient or community from imminent and substantial danger.
We may disclose your health information to the extent such records are reasonably related to any injury for which workers compensation is claimed.
Cardiology Associates wil not make any other use or disclosure of your protected health information without your written authorization. You may revoke suchauthorization at any time, except to the extent that Cardiology Associates has taken action in reliance thereon. Any revocation must be in writing.
Your Rights Regarding Your Protected Health Information You are permitted to request that restrictions be placed on certain uses or disclosures of your protected health information by Cardiology Associates to carryout treatment, payment, or healthcare operations. You must request such a restriction in writing. We are not required to agree to your request, but if we doagree, we must adhere to the restriction, except when your protected health information is needed in an emergency treatment situation. In this event,information may be disclosed only to healthcare providers treating you. Also, a restriction would not apply when we are required by law to disclose certainhealthcare information.
You have the right to review and/or obtain a copy of your healthcare records, with the exception of psychotherapy notes, or information compiled for use (or inanticipation for use) in a civil, criminal, or administrative action or proceeding. Cardiology Associates may deny an access under other circumstances, in whichcare you have the right to have such a denial reviewed. We may charge a reasonable fee for copying your records.
You may request that Cardiology Associates send protected health information, including bil ing information, to you by alternative means or to alternativelocations. You may also request that Cardiology Associates not send information to a particular address or location or contact you at a specific location,perhaps your place of employment. This request must be submitted in writing. We wil accomodate reasonable requests by you.
You have the right to request that Cardiology Associates amend portions of your healthcare records, as long as such information is maintained by us. Youmust submit this request in writing, and under certain circumstances the request may be denied.
You may request to receive an accounting of the disclosures of your protected health information made by Cardiology Associates for the six years prior to thedate of the request, beginning with disclosures made after April 14, 2003. We are not required, however, to record disclosures we make pursuant to a signedconsent or authorization.
You may request and receive a paper copy of this Notice, if you had previously received or agreed to receive the Notice electronical y.
Any person or patient may file a complaint with Carediology Associates and/or the Secretary of Health and Human Services if they believe their privacy rightshave been violated. To file a complaint with Cardiology Associates, please contact the Privacy Officer at the fol owing: It is the policy of Cardiology Associates that no retaliatory action wil be made against any individual who submits or conveys a complaint of suspected oractual non-compliance or violation of the privacy standards.
This Notice of Privacy Practices is effective April 14, 2003.

Source: http://www.cardiologyassociates.info/Patient%20Forms.pdf