new patient registration for women · mcminn clinic 3125 independence drive suite 108 homewood, al...

Welcome to the McMinn Clinic and thank you for choosing to partner with us in your healthcare journey. Below are the forms that you will need for your first visit.

There are 3 different options for completing and printing the form: Note the PRINT button at the top of the first section-this will print the entire form

1. You can download and save the form to your computer. You can then completeand print the form. This also gives you the option to save a completed copy toyour computer.

2. You can complete the form online and then print it. If you complete the form andprint it directly from the website, your information is NOT saved to the websiteand the form is cleared once you close the form.NOTE: If you complete the form prior to downloading it to your computer, youwill not be able to save a completed copy to your computer. (It will only downloadthe blank form.)

3. You can print the form directly from the website and complete it “by hand.”4. Please print the form "one-sided" only; please do not print form front and back.5.

New Patient Registration for Women

Items highlighted in yellow (initial/signature blanks) must be completed "by hand."

If you are having your lab work done at our office, please bring the completed forms with you when you come in for your lab appointment. If you are having your labs done elsewhere, please bring the completed forms with you to your first visit. We look forward to working with you to optimize your health!

As you scroll down, you will find the following sections:

• Patient Registration• Patient Medical History• Gut Health Questionnaire (if your visit concerns gut health)• Authorization for Treatment• Prior Authorization Information• Private Service Agreement• No-Show Policy• Cancellation Fee Policy• Authorization to Release Medical Information• Credit Card Information• Notice of Privacy Practices

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McMinn Clinic 3125 Independence DriveSuite 108 Homewood, AL 35209 Phone: 205-868-1313 Fax: 205-868-1314

NEW PATIENT REGISTRATION

Name:_______________________________________ Today’s Date:___________________

Address:_____________________________________________________________________

City:_____________________ State:______ Zip:__________ Date of Birth:______________

E-mail:___________________________ Social Security Number:_______________________

Home Phone:_______________ Cell Phone:______________ Work Phone:______________

Occupation:_________________________ Place of Employment:_______________________

Status: Married Long-Term Relationship Single Divorced Widowed

Name of Policy Holder:_________________________________________________________

Date of Birth of Policy Holder:__________________ Relationship to Policy Holder:_________

Place of Employment of Policy Holder:_____________________________________________

Emergency Contact:______________________________ Phone:_______________________

Other Medical Provider(s):______________________________________________________

Name of Pharmacy:_______________________________ Phone:_______________________

Reason for Visit:_______________________________________________________________

Allergies:____________________________________________________________________

How did you learn about McMinn Clinic? ___________________________________________

Patient’s Printed Name:_________________________________________________________

_____________________________________________ _____________________________ Signature of Patient or Authorized Representative Date

Revised March 2018

ll ri ht re er ed ame E i D

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Page of Revised March 2018

McMinn Clinic 3125 Independence Drive Suite 108 Homewood, AL 35209

NEW PATIENT MEDICAL HISTORY

Phone: 205-868-1313 Fax: 205-868-1314

NAME:

MALE FEMALE DATE OF BIRTH:

PRIMARY CARE DOCTOR: PHONE NUMBER:

WHEN DID YOU LAST HAVE A PHYSICAL EXAM:

PRIMARY HEALTH CARE CONCERN/PROBLEM:

HEALTH EXPECTATION FROM YOUR VISIT TO MCMINN CLINIC:

ALLERGIES TO MEDICATIONS? NO YES If yes, what medication(s):

ALLERGIES TO FOODS? NO YES If yes, what food(s):

ALLERGIES TO INSECT BITES? NO YES If yes, what insect and what type of reaction?

DO YOU SMOKE?

NO YES If yes, what do you smoke?

How long? How many per day?

DO YOU DRINK ALCOHOL?

NO YES If yes, what and how often:

DO YOU DRINK CAFFEINATED BEVERAGES?

NO YES If yes what and how many drinks per day?

HAVE YOU GAINED OR LOST WEIGHT WITHIN THE LAST YEAR? NO YES If GAINED, how much If LOST, how much

DO YOU HAVE A HISTORY OF ANY EATING DISORDER SUCH AS ANOREXIA OR BULIMIA?

NO YES If yes, please explain:

DO YOU EXERCISE REGULARLY? NO YES If yes, what type of exercise and how often


Page of Revised March 2018

LIST ALL MEDICATIONS ou are currently taking, PRESCRIPTION/OVER THE COUNTER/BIRTH CONTROL ANY VITAMINS OR SUPPLEMENTS

MEDICATIONS / SUPPLEMENTS REASON

LIST ANY SERIOUS ILLNESSES / SURGERIES / HOSPITALIZATIONS

ILLNESSES / SURGERIES / HOSPITALIZATIONS YEAR

HAVE YOU BEEN UNDER A PHYSICIAN’S CARE IN THE PAST 5 YEARS FOR AN ONGOING MEDICAL ISSUE OR UNDER THE CARE OF A PSYCHIATRIST? NO YES If yes, please explain

DO YOU KNOW OF ANY CONDITION FOR WHICH YOU BELIEVE YOU WILL NEED TREATMENT (MEDICAL OR SURGICAL)? NO YES If yes, please explain

____________________________________


Page of Revise March 2018

r w r cr

GENERAL: MOUTH AND THROAT: Sores in / around mouth Frequent colds or sore throats Trouble swallowing Persistent hoarseness Other problems:

LUNGS: Shortness of breath Asthma / wheezing Chronic cough TB or exposure to TB Other problems:

Fatigue Loss of appetite Night sweats Fever / Chills Increased thirst Increased hunger

SKIN: Rash Itching Change in hair Other problems:

NEURO: Headaches Migraines Dizziness Seizures Tremors Other problems:

EYES: Vision problems Glaucoma Cataracts Other problems:

EARS: Hearing problems Ringing in ears Other problems:

NOSE: Sinus infections Sinus congestion

NECK: Neck stiffness Pain or tenderness Thyroid problems Other problems:

GENITO-URINARY: Painful urination Frequent urination Urination at night Feeling of pressure on bladder Difficulty starting urination Inability to hold urine Kidney stones Frequent urinary infections Sexually transmitted disease Change in sex drive Other sexual problems: ________________________ _ Other problems:

HEART: Heart palpatations Swelling of feet or ankles Cool / pale hands or feet Pain in legs when walking Hypertension Previous heart attack Mitral valve prolapse Other problems:

BLOOD: Anemia HIV / AIDS Easy bruising Previous blood transfusions Other problems:

MUSCULOSKELETAL: Pain in bones or joints Redness/swelling in bones or joints Limitation of range of motion Muscular weakness Muscular cramps Arthritis Gout Back problems Problems with walking Numbness in hands or feet Other problems:

PSYCHOSOCIAL: Anxiety Depression Difficulty remembering Frequent episodes of sadness/crying

Nose bleeds Other problems:

BREAST: Lumps or swelling Cancer Tenderness Nipple discharge Other problems:

DIGESTIVE: Change in appetite or digestion Frequent indigestion Abdominal pain / cramps Frequent diarrhea Frequent constipation Recent change in bowel habits Blood in stools Colitis/Crohn's Hepatitis IBS Other problems:

____________________________________

PATIENT HISTORY RECORD: Please check only what applies to medical history


DISEASE YES NO WHICH FAMILY MEMBER(S) Cancer Heart disease Stroke High lood ressure Diabetes Kidney disease Tuberculosis Glaucoma Sickle cell

Seizures Arthritis Gout Alcoholism Drug addiction

Suicide Other

RELATIVE AGE, IF LIVING PRESENT HEALTH IF DECEASED, AGE AT

DEATH AND CAUSE Mother Living Deceased Father Living Deceased Children Living Deceased Spouse Living Deceased Brothers # Living ___ #Deceased____ Sisters # Living ___ #Deceased____

Revised March 2018 Page of

____________________________________

FAMILY HISTORY Check box below if your mother, father, brother, or sister have had any of the following


HOT FLASHES.............

NIGHT SWEATS............

LOW ENERGY..............

LOW LIBIDO.................

LOW MOOD..................

VAGINAL DRYNESS.....

SLEEP PROBLEMS......

BRAIN FOG...................

URINE LEAKAGE..........

ACHES AND PAINS......

UTERINE FIBROIDS....

FIBROUS BREASTS.....

MOOD SWINGS............

PMS..................................

ASTHMA........................

ALLERGIES...................

IRRITABILITY.................

ANXIETY..........................

DIARRHEA...........................

LESS MOTIVATION.............

REDUCED MUSCLE STRENGTH......

BELLY PAIN.........................

FACIAL WRINKLES.............

HEADACHES.......................

MORE EMOTIONAL.............

WEIGHT GAIN.......................

COLD HANDS AND FEET......

HAIR LOSS...........................

BREAST TENDERNESS......

DRY SKIN.............................

CONSTIPATION...................

BRITTLE NAILS...................

OSTEOPOROSIS ................P AI NFUL INTERCOURSE....

LOW BODY TEMP...............

LOW BLOOD PRESSURE...

when was your last mammogram? ___________________ have you ever had an abnormal mammogram? Yes No

When was your last Pap Smear? _________________ Yes No Have you ever had an abnormal Pap Smear?

Revised March 2018 All rights reserved © 2009 James E. McMinn, M.D.

FEMALE HORMONE TRACKING SHEET

Name_______________________________________________ Date___________________

Mark the appropriate number indicating the intensity of your problem: 0 = none 1 = mild 2 = moderate 3 = severe 4 = extreme

0 1 2 3 4 0 1 2 3 4

______________________________________________________________________________ Have you had a hysterectomy? Yes No If NO, when was your last menstrual period? ______________________

Yes No Have you ever had a mammogram? If YES

LOW PULSE............................

Page 6 of 6

NEW PATIENT MEDICAL HISTORY 3125 Independence DriveSuite 108 Homewood, AL 35209


This form needs to be completed ONLY if you have gut health concerns

Gut Health Questionnaire

Name:____________________________________ Date:_________________

• Please briefly describe your current gut condition, including any known diagnosis

______________________________________________________________________________

• How long have you had this condition?_______________________________________________

• Were there any known triggers that occurred before or about the same time as the condition (foodpoisoning, major stress, antibiotics, etc.)?

•

• Does your condition tend to run in your family? Yes No

If so, with whom?________________________________________________________________

General Questions Let’s start at the beginning: o Were you born by C-section or vaginal birth? o Were you breast fed or bottle fed?

o Were you on antibiotics as a child (0-3 years old)?o Did you have a fairly happy childhood (up to 18 years old)?o Have you taken antibiotics more than 4 times in your life?o Have you ever taken antibiotics for longer than 2 weeks at a time?o Did you take antibiotics for acne?o Have you been on birth control pills?o Have you taken stomach acid suppressors (like Prilosec, Nexium,

or Zantac) for more than month at a time?o Do you take NSAID drugs regularly (like Motrin, Advil,

Aleve, or Naprosyn?o As a child did you eat a lot of vegetables?o Do you (or have you in the past) tend to eat a lot of sugar or

starchy food?o Do you tend to drink more than 10 alcoholic beverages per week?o Do you tend to drink one or more sodas or diet sodas per day?o Have you ever experienced traveler’s diarrhea?o Have you ever been diagnosed with a parasite?o a e o had t r er h a all ladder or olo r er

Page 1 of 2

Phone: 205-868-1313 Fax: 205-868-1314

ll ri ht re er ed ame E i D reated e

Name:______________________________

Signs and Symptoms Associated with Unhealthy Gut Please mark any condition that you’ve experienced:

Acne Eczema Rosacea Food allergies Sensitivities Bad breath Bloating Gum disease

Excessive / foul-smelling gas Chronic yeast problems (skin, vagina, nails, etc.) Brain fog Poor immune function Depression Anxiety Unexplained fatigue

Difficulty losing weight Excessive mucous in stools Acid reflux Food poisoning Chronic diarrhea Chronic constipation Anal itching Vaginal itching

Conditions That May Be Associated with Unhealthy Gut Please mark any condition that you’ve experienced:

Autoimmune Disease (such as lupus, MS, or Hashimoto’s) Celiac Disease or Gluten Sensitivity Diabetes Bacterial Vaginitis Ulcerative Colitis Crohn’s Disease

Leaky Gut Microscopic Colitis IBS SIBO (small intestinal bacterial overgrowth) Obesity Frequent or Chronic Sinusitis Thyroid Disease

Page 2 of 2

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hi form eed to e om leted if o ha e t health o er

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Authorization for Treatment at McMinn Clinic

Functional Medicine is the practice of medicine which attempts to look for and treat the underling root cause of the problem.

Integrative Medicine is the practice of medicine which seeks to find the best solution(s) for the problem by using both traditional medical therapies and alternative therapies, such as (but not limited to) nutritional therapies.

I understand that Functional and Integrative medicine are practiced at McMinn Clinic. I understand that in the practice of functional medicine and integrative medicine some treatments are considered investigational, experimental, or alternative by the conventional medical community, and that there may be some risks to treatment. I do not expect the Doctor or other employees or agents of McMinn Clinic to be able to anticipate and explain all possible risks and complications, and I wish to rely on the medical provider to exercise judgment during the course of treatment based upon the facts then known and in my best interest.

As a service to the patient, McMinn Clinic makes nutritional supplements available in our office. You are under no obligation to purchase these products in our office. Refunds will be given to any supplement that is unopened and returned within 14 days of purchase.

I also testify that I present to McMinn Clinic on my own accord and for my own purposes and not on behalf of a third party such as a government agency.

I have read and/or have had read to me the above consent. I have also had an opportunity to ask questions about its content. By signing below, I understand the above information. I intend this consent form to remain in effect for the entire course of my treatment for my present condition and for any future conditions for which I seek treatment.

_______________________________________ ____________________ Printed Name of Patient Date

_______________________________________ Signature of Patient

Revised June 2018

Name_____________________

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McMinn Clinic Phone: 205-868-1313 3125 Independence Drive Fax: 205-868-1314 Suite 108 Homewood, AL 35209

What is a Prior Authorization and what does it mean for me?

A prior authorization (PA) is a requirement by your health insurance company that your provider obtain approval for payment of a specific prescribed medication. A PA is not required for ALL medications. Though a PA requirement is intended to minimize medical costs for the insurance company, the PA request must be completed and filed by the prescriber’s medical office. At McMinn Clinic, our nurses are highly skilled at navigating the PA approval process.

Your insurance company likely will not pay for the prescribed medication unless they approve your PA. It is the insurance company, not your prescriber, that has the final say as to whether or not your medication will be paid for by your insurance company.

If your insurance company denies your PA, this DOES NOT MEAN that you cannot have your medication filled at a pharmacy. However, it does mean that YOU, and not your insurance company, will be responsible for paying for the medication.

When your insurance company approves a PA, it is usually for a defined period of time, such as 6 months or 1 year. The time length can and does vary.

How does McMinn Clinic help me with a Prior Authorization, should my prescribed medication require one?

While the nurses at McMinn Clinic are highly skilled in filing the request for PA approval, the process can be very time consuming, often requiring research for previous treatment, often looking back years at a time. Therefore, it is necessary to charge for this service.

• FIRST Prior Authorization request: No charge to the patient.

• All subsequent Prior Authorization requests for medications (either the samemedication or a different medication): $30 charge to the patient each time a PA is filed.

(NOTE: McMinn Clinic no longer files Prior Authorizations for HCG.)

Name______________________________________________________________________

Signature_____________________________________________Date__________________

Revised April 28, 2018 All rights reserved (c) 2012 James E. McMinn M.D.

Name___________________________

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PRIVATE SERVICE AGREEMENT

Provider's Opt Out of Medicare: James McMinn, M.D. (the "Provider") has exercised his ability to opt out of the Medicare program effective June 1, 2013 for the Medicare program under 1128, 1156,1892 or any other section of the U.S. Social Security Act.

Client Responsibility for Provider Charges: The client designated above (the "Client") is, or may become, a Medicare beneficiary during the Opt Out Period and has requested that the Provider render professional services to Client during the Opt Out Period. Client, or Client's legal representative, as the case may be, hereby accepts full responsivity for payment of the Provider's charges for all services furnished by the Provider.

No Medicare Limits and Payments: Client understands: • That any Medicare limits do not apply to what the Provider may charge or item s or services he/she furnishes• That no Medicare payment will be made for any items or services furnished by the Provider that would

have otherwise been covered by Medicare if this Private Service Agreement did not exist and a properMedicare claim had been submitted

No Submission of Medicare Claims:The Client or Client's legal representative as the case may be, agrees• Not to submit a claim to Medicare• Not to ask the Provider to submit a claim to Medicare

Client Rights: The Client or Client's legal representative as the case may be, enter into this Private Service Agreement with the knowledge that Client • Has the right to obtain Medicare covered items and services from physicians and practitioners who have not

opted out of Medicare• Is in no way compelled to enter into any private service agreements that apply to other Medicare covered

services furnished by other physicians or practitioners who have not opted out

Medigap and Other Supplemental Plans:The Client, or Client's legal representative as the case may be, understands that Medi-gap plans do not, (andthat other supplemental plans may elect not to), make payments for items and services not paid for byMedicare.

Emergency or Urgent Care Services:Provider and Client agree that they are not entering into this Private Services Agreement during a time whenClient requires emergency care services or urgent care services, which include either services furnished in thetreatment of an emergency medical condition or services furnished to an individual who requires services to befurnished within 12 hours in order to avoid the likely onset of an emergency medical condition.Now therefore, Provider and Client hereby execute this Agreement to be effective for services renderedby Provider to Client.

______________________________ Date

Revised March 2018


Phone: 205-868-1313 Fax: 205-868-1314

ame_____________________________________

______________________________________________________ lie t i at re

All rights reserved © 2012 James E. McMinn, M.D.

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NO-SHOW POLICY

Name_______________________________________________

The entire staff at McMinn Clinic would like to thank you for allowing us to be your partner in your journey toward optimal wellness.

One of the fundamental tenets of care at McMinn Clinic is that we give each patient adequate time to be truly heard. We pride ourselves in being good listeners. For most of our patients, we block out an hour of our provider’s time. This allows us to better get to the root of the problem and, ultimately, for the patient to have an optimal outcome.

Routinely, we attempt to call each patient a day or t o before the appointment to remind him/her of the appointment. We ask, in turn, that each patient arrive at the agreed-upon time or call us 24 hours in advance to cancel the appointment.

EFFECTIVE IMMEDIATELY:

• McMinn Clinic will securely keep on file a valid credit card number for each patient.

• If the patient needs to cancel the appointment, he/she shall call us 24 hours before theappointment (business hours only-not weekend or holiday hours) to cancel theappointment.

• If proper notice is not given, and the patient does not arrive for the appointment, then acancellation fee will be charged to the credit card (see Cancellation Fee Policy).

• If there is an emergency and the patient is not able to make the appointment, the patientmay discuss the extenuating circumstances with the ra ti e admi i trator.

Thank you again for allowing us to be a member of your health-care team. Working together, we can help you to be the best that you can be in mind, body, and spirit.

Signature_________________________________________ Date____________________

Revised March 2018



Name_________________________________________

Cancellation Fee Policy Should a patient/client not show for a scheduled appointment or should a patient/client cancel his/her appointment less than 24 hours (business days only-not weekends or holidays) prior to the scheduled appointment, the following fee must be paid before another appointment can be scheduled.

1-hourappointment

30-minuteappointment

15-minuteappointment

Dr. McMinn $395 $295 $175

Dr. Brunsvold $350 $275 $150

Nurse Practitioner $295 $150 $ 95

Dietitian $ 90 $ 45 n/a

Health Coaching $ 99 n/a n/a

Counseling $ 90 $ 45 n/a

IV Therapy

1st Cancellation / No Show: 50% of appointment cost 2nd Cancellation / No Show: 100% of appointment cost After 2nd Cancellation / No Show, additional IV appointments must be pre-paid, including any additional fees, before the appointment will be scheduled.

If the appointment is for a free consultation, patient/client will not receive another free consultation.

If any additional appointments result in a “no-show” or “late cancellation,” the full amount for the missed appointment must be paid and additional appointments must be prepaid before they will be scheduled.

If there is an emergency and the patient/client does not make the appointment and is unable to give a 24-hour notice, the patient/client may discuss the issue with the office manager.

I have read the cancellation policy above and I agree to comply with cancellation policy of McMinn Clinic.

___________________________________________ ______________________ Patient/Client Signature Date

James McMinn, M.D._______________________ Owner

Revised Aug., 2018 All rights reserved (c) 2012 James E. McMinn M.D.


AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Name________________________________________

Please list below the name(s) of the people to whom you authorize the release of your medical information:

This may include, but is not limited to, picking up prescription for you, changing appointments for you, discussing your medical information during phone consults, and/or being present during your visit with your provider and his staff.

______________________________________________ _________________________ Name Relationship



AUTHORIZATION TO CONTACT ME

Confidentiality cannot be ensured with any form of communication through electronic media. I give McMinn Clinic permission to contact me in the following way(s):

• Call Home: Number___________________ Yes No Leave Message: Yes No

• Call Cell: Number____________________ Yes No Leave Message: Yes No

• Text Cell: Number____________________ Yes No

• Email: Email Address______________________________________ Yes No

• Home: Home Address:______________________________________ Yes No

______________________________________________ _________________________ Patient’s Signature Date

Revised June 2018

__________________ _____ ___________

CREDIT CARD INFORMATION

Patient’s Name______________________________________

We ask that you keep current credit card information on file with McMinn Clinic. This confidential information will be used for phone consult charges, purchasing supplements that you may want us to have ready for pick-up or mailing, as well as for missed appointments. A receipt can be mailed to you upon request. Otherwise, the receipt can be accessed in our system anytime you request a copy. The information you provide here will be kept confidential and will be used only for the purpose stated above, unless otherwise discussed with you prior to charging your credit card.

CREDIT CARD TYPE:

Mastercard Visa American Express Discover Care Credit

Credit Card Number:_____________________________________________________

CVC:___________________ or AmEx (4 digits on front of card)__________________

Expiration Date:________________________________________________________

Mailing zip code of the above credit card:____________________________________

_____________________ ____________________________________________i at re of ardholder Date

Revised March 2018


Phone: 205-868-1313 Fax: 205-868-1314


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Revised July 2018 cam All rights reserved © 2010 James E. McMinn, M.D.* (page 1 of 2)

1) maintain the confidentiality of yourPHI in accordance with federal and/orstate law;2) comply with the terms of this noticeuntil it is replaced with a new notice;and3) give you the notice of our legalduties and privacy procedures withrespect to PHI we maintain about you.We reserve the right to change the terms of this notice at any time. We also reserve the right to make the changes apply to your PHI we already have. Before we make a material change of this notice, we will promptly post a new notice in a clear and prominent area of our clinic. You can also request a copy of the new notice from our staff. We may use or disclose your PHI without your authorization for treatment, payment and health care operations as explained below: For treatment: We may use and

disclose your PHI to the physicians, nurses and other health care personnel who provide, coordinate or manage your health care in any related services. We may also disclose your PHI to another health care provider at a different location at his/her request for your treatment by him/her. For payment: We may use and disclose your PHI in order to bill and collect payment for services provided to you. We may also disclose your PHI to the responsible party of your account, to a collection agency, or to an ambulance/transportation company which provides services to you. For health care operations: We may use and disclose your PHI in order to support our business activities, such as quality assurance. We may use and disclose your PHI to other health care providers, health plans or health care clearinghouses for their limited health care operations, such as quality assessment activities, licensing and other health care compliance activities. For business activities: We may disclose your PHI to our business associates that assist us in the delivery of health care and related services, such as billing companies, lawyers, accountants and others. Before we disclose your PHI to our business associates, we will have a written contract with each of them that will require each to agree to maintain the privacy of your PHI. Below are other reasons we may disclose your PHI without your consent or authorization: Uses and disclosures required by law: We may use or disclose your PHI as required by law but must limit such use or disclosure to relevant information and otherwise comply with applicable legal requirements. Public health activities: We may use or disclose your PHI to the public health authorities to receive or collect information for public health progress,

such as preventing and controlling disease and for certain regulatory activities of the Food and Drug Administration. Abuse, neglect, or domestic violence: We may use or disclose your PHI in some instances if we reasonably believe that you are a victim of abuse, neglect or domestic violence. Health oversight activities: We may use or disclose your PHI to a health oversight agency for health oversight activities authorized by law including, for example, inspections and licensure of health care facilities. Judicial and administrative proceedings: We may use or disclose your PHI for law enforcement purposes to law enforcement officials, such as for identification of suspects or where a crime has been committed on our premises. Inmates: If you are an inmate at a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution for purposes that include (1) providing you with health care; (2) protecting your health and safety and the health and safety of others; or (3) protecting the safety and security of the correctional institution. Decedents: We may use or disclose PHI about decedents to coroners, medical examiners, and funeral directors. Research: In limited circumstances, we may use and disclose your PHI to conduct medical research. Serious safety threat: We may use or disclose your PHI when we believe it is necessary to prevent or lessen a serious threat to the safety of a person or the public. Special government function: We may use or disclose your PHI under some circumstances for special government functions, including those

NOTICE OF PRIVACY PRACTICES

Patient’s Name: ________________________________

Initials________

The staff of McMinn Clinic values your relationship with us, and we are grateful that you chose us to be a part of your health care program. We are fully committed to safeguarding the privacy of your protected health information (PHI) that is in our possession. PHI is any information that we possess, use, and disclose that identifies you and related to your past, current, or future physical and mental health condition or illness and the health care products and services that have been provided to you. Please review this information carefully. We are required by law to:

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related to the armed forces, national security and intelligence. Worker’s compensation: We may use or disclose your PHI authorized by and to the extent necessary to comply with the laws related to worker’s compensation and similar programs. Scheduling appointments, appointment reminders, and health related benefits or services: We may use or disclose your PHI to schedule appointment reminders and give you information about treatment alternatives or other health care related services or benefits we offer. To your personal representative: We may disclose your PHI to your personal representative that is appointed by or authorized by applicable law. Potential impact of state: In some situations, the federal privacy laws do not preempt state law of greater privacy protections. As a result, the privacy laws of a particular state might impose a privacy standard which we will be required to operate.

Uses and disclosures for which you have an opportunity to agree or object: Individuals involved in your care: We may disclose your medical information to a family member, friend, or other person that you indicate is involved in your care or the payment of your health care, unless you object in whole or in part. The opportunity to agree or object may be given retroactively in emergency situations.

Your authorization is needed for other uses and disclosures. We may not use or disclose your PHI for any other purposes unless you give us written authorization to do so. If you give us written authorization to use or disclose your medical information for a purpose that is not described in this notice, then in most cases, you may revoke it in writing at any time. Your revocation will be effective for all your PHI that we maintain unless we have taken action in reliance of your authorization.

WHAT RIGHTS TO YOU HAVE REGARDING YOUR PHI? The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides you with several rights related to your PHI. You have: * the right to request additional

restrictions on the uses and disclosures of your PHI. We do not have to agree or comply with your request. * the right to inspect and copy your

PHI that we may use to make decisions about you. In limited circumstances, we do not have to agree with your request. * the right to amend or correct if you

feel that your PHI is incorrect or incomplete. We will require that you submit the request in writing to explain your reasons for asking for an amendment. In some cases, we do not have to agree to your request. * the right to request confidential

communications. You have the right to request that we communicate with you about medical matters by a different means or at a different location than what we are currently doing. In limited circumstances, we do not have to agree to your request. * the right to request and receive a

paper copy of this notice if you received it by email or on the internet. * the right to the accounting of

disclosures. You have the right to request a list of certain disclosures that we and our business associates made for a certain purpose for the last 6 years, except for disclosures made before April 14, 2003. If you want to exercise any of these rights described in this notice, please contact us at (205) 868-1313. We may give you the necessary information and forms you to complete and return to us. In some cases, we may charge you a nominal fee to carry out your request. How to complain about our privacy practices: If you think we have violated your privacy rights, you may file a

complaint. You may contact us directly or you may send a written complaint to the Secretary of the Department of Health and Human Services. We will not take retaliatory action against you if you file a complaint about our privacy practices. Disclosure for relatives, close friends, and other caregivers: We may use or disclose your PHI to a family member, other relative, or close personal friend or any other person identified by you when you are present for, or otherwise available prior to, the disclosure, if we (1) obtain your agreement, (2) provide you with the opportunity to object to the disclosure and you do not object; and (3) reasonably infer that you do not object to the disclosure. _____ (please initial) We may exercise our professional judgment to determine whether a disclosure is in your best interest if you are not present, or if you do not have the opportunity to agree or to object to a use or disclosure of your information. If we disclose information to a family member, other relative or a close personal friend, we would disclose only information that we believe is directly relevant to the person’s involvement in your health care or payment related to your health care. We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location or general condition. _____ (please initial) I have read the Notice of Privacy Practices of McMinn Clinic. Name: _______________________________ Signature: _______________________________

Date: __________________________

(page 2 of 2)

Revised July 2018 cam

All rights reserved © 2010 James E. McMinn, M.D

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new patient registration for women · mcminn clinic 3125 independence drive suite 108 homewood, al...

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