restoration healthcare, inc. restoration 18818tellerave...

RESTORATION HEALTH CARE

To: Restoration Healthcare

Fax: 949-535-2330

Phone: 949-535-2333

Re: Patients forms

Greetings,

From:

Pages: 19

Date:

Restoration Healthcare, Inc. 18818TellerAve. Suite 170

Irvine, CA 92614

m 949.535.2322 (F)949.535.233o

(patient)

These are the forms to establish yourself as a patient in our office

Please complete the following;

(Leave about 40-60 minutes to complete)

1.Attached forms

2. Copy Front and Back of Insurance Card

(If you have any difficulty filling out the forms we can assist you when you arrive at the office)

Send them back to us either;

via the above fax sheet

or

email: [email protected]


Restoration Healthcare, Inc. 18818 Teller Ave. Suite 170

Irvine, CA 92614 (T) 949.535.2322 (F) 949.535.2330

MEDICAL HISTORY QUESTIONNAIRE

Patient Information:

Patient Name: (Last) __________ (First) __________ (Ml) __ _

Name you prefer to be called: _______________________ _

Patient Address: __________________________ _

City: ________________ State: _____ Zip: _____ _

Home Phone: Work/Cellular: _________ _

Date of Birth: Age: ______ Sex: M F

E-Mail Address:------------------------

Do you have health insurance? Yes or No Name of insurance: ___________ _

Employment Information:

Patient Employer: ___________ Occupation: _________ _

Employer Address: _________________________ _

City: ________________ State: _____ Zip: _____ _

Work Phone No: ______________ Ext. ___________ _

In Case of Emergency:

Name: _____________ Relationship: ______ _

Phone: ______ _

Patient's Spouse: __________________ _

Phone: ______ _

Family Physician: ___________________ Phone: ______ _

Who may we thank for referring you to us? ___________________ _

General Health Present Status: 1. Are you in good health at the present time to the best of your knowledge? Yes No 2. Are you under a doctor's care at the present time? Yes No 3. Are you taking any medications at the present time, including beta blockers, heart or Pain medications? Yes No

4. History of Constipation (difficulty in bowel movements) Yes No 5. History of Frequent Headaches? Yes No 6. Migraines? Yes No 7. Do you smoke? Yes No 8. History of Heart Attack or Chest Pain? Yes No 9. Any allergies to any medications? Yes No

10. Do you suffer from allergies Yes No 11. History of Glaucoma? Yes No 12. History of High Blood Pressure? Yes No 13. History of Swelling Feet? Yes No 14. History of Diabetes? Yes No 15. History of Sleep Apnea Yes No 16. Serious Injuries? Yes No

17. Any Surgery? (non-orthopedic)

I

Yes No

Past Medical Histor : (Check all that apply)

HIV Kidneys Liver Disease

Lung Disease Bleeding Disorder Eating Disorder

Arthritis Alcohol Abuse Thyroid Disease

Anemia Heart Valve Disorder Heart Disease

Cancer Gallbladder Disorder Psychiatric Illness

Drug Abuse Other:

Family Medical History: (Check all that apply)

High Blood Pressure Nervous Breakdown Heart Trouble

Cancer Strokes Anemia

Obesity Kidney Disease Suicide

Migraine Allergy Bleeding (abnormal)

Arthritis Epilepsy Syphilis or bad blood

Reproductive Health Female Histor

1. Menopause Yes No 2. Average Cycle Duration (in days) 3. Are you regular? 4. Pain Associated? 5. Last Menstrual Period 6. Birth Control 7. Last Annual Exam

(Check all that apply) __ Low Libido

__ Decreased Muscle Mass

__ Lack of Energy

__ Sleep Disturbances

__ Poor Memory I Concentration __ Sadness

Male History:

Sexual Function: Performing Erection Orgasm (Check all that apply) __ Low Libido __ Performance

__ Decreased Muscle Mass __ Sleep Disturbances

__ Orgasm _Erectile Dysfuntion

Yes No Yes No _;_;_ Yes No _;_;_

__ Decreased Strength

__ Hair Loss

__ Decreased Enjoyment of Life

Enjoying Pain During/ After

__ Decreased Strength

__ Hair Loss

__ Decreased Enjoyment of Sex

Past Medical History: (Check all that apply)

HIV Kidneys Liver Disease

Lung Disease Bleeding Disorder Eating Disorder

Arthritis Alcohol Abuse Thyroid Disease

Anemia Heart Valve Disorder Heart Disease

Cancer Gallbladder Disorder Psychiatric Illness

Drug Abuse Other:

Family Medical History: (Check all that apply)

___ High Blood Pressure Nervous Breakdown ___ Heart Trouble

___ Cancer Strokes __ Anemia

___ Obesity Kidney Disease ___ Suicide

___ Migraine Allergy ___ Bleeding (abnormal)

___ Arthritis Epilepsy ___ Syphilis or bad blood

Nutritional Health Nutritional Assessment:

1. Do you awaken hungry during the night? Yes No 2. How often do you eat out?--------------------3. How often do you eat "fast foods"?-----------------4. Do you wake up in the morning hungry? Yes No 5. What time of the day are you most hungry? _______________ _

What is your activity level?

__ Inactive- No regular physical activity with a sit down job

__ Light activity- No organized physical activity during leisure time

__ Moderate Activity- Occasionally involved in activities such as weekend golf, tennis, jogging, swimming or cycling

__ Heavy Activity- Consistent lifting, stair climbing, heavy construction, etc., or regular participation in jogging, swimming, cycling or active sports at least three times per week

__ Vigorous Activity- Participation in extensive physical exercise for at least 60 minutes per session 4 times per week

6. On average how many hours of sleep do you get per night?-------------

Allergies Allergy Assesment: (Check all that apply)

The symptoms most commonly associated with allergies include: o Runny nose (clear discharge) o Episodic sneezing o Coughing o Wheezing (if asthmatic) o No of fever o Nasal congestion (stuffy nose) o Post nasal drip o Itchy /Watery eyes

Itchy /Watery eyes

Less commonly noted symptoms include: o Headaches o Ear itching, popping and fullness o Fatigue, irritability o Loss of sense of smell and taste o Sleep disturbance

o Snoring o Low productivity and poor

concentration

Heavy Metal Toxicity Heavy Metal Toxicity Symptoms:

o Have you had sore gums (gingivitis) often over the years?

o Have you had mental symptoms such as confusion, forgetfulness?

o Have you had ringing in the ears (tinnitus)?

o Have you had unusual shakiness (tremors) of your hands and arms or twitching of other

muscles?

o Do you have "brown spots" or "age spots" under your eyes or elsewhere on the skin of your

body?

o Have you tended to have more colds, flu, and other examples of infectious diseases than

"normal"?

o Have you had food allergies or intolerance's?

o Have you been to many doctors for your health problems and they have usually said "there is

nothing wrong"?

o Do you have numbness or burning sensations in your mouth or gums?

o Do you have numbness or unexplained tingling in your arms or legs?

o Do you have 10 or more "silver" fillings?

o Do you often have a "metallic" taste in your mouth?

o Have you ever worked as a painter or in manufacturing/chemical or pesticide/fungicide factories

(fungicides with methyl mercury ingredients) or in pulp/paper mills that used mercury?

o Have you worked as a dentist, hygienist or dental assistant?

o Have you ever had Candida Related Complex (CRC) or yeast infections of the vagina, mouth or GI

tract?

o Do you have a lot of bad breath (halitosis) or white tongue (thrush)?

o Have you frequently had low basal body auxiliary temperature (below 97.4 degrees F.) over the

years?

o Do you have problems with constipation?

o Do you have heart irregularities or rapid pulse (tachycardia)?

o Do you have unexplained arthritis in various joints?

o Is it common for you to have a lot of mucus in your stools?

o Do you have unidentified chest pains even after EKG's, X-ray, and heart studies are normal?

o Is your sleep poor or do you have frequent insomnia?

o Have you had frequent kidney infections or do you have significant kidney problems?

o Are you extremely fatigued much of the time and never seem to have enough energy?

o Do you have irritability or dramatic changes in behavior?

o Are you on antidepressants now or have been in the past?

Orthopedic Health

Sports Injuries, and Musculoskeletal Issues:

WHERE IS YOUR PAIN LOCATED? (Be Specific and Label Worst Area) PATIENT TO DRAW

RIGHT PAIN LEVEL I 2

MILD 3 4 5

RIGHT 6 7 8

MODERATE 9 10

SEVERE

DATE OF INJURY /onset ________ _ How did you get hurt? (Please give details including dates and places)

Has this been a problem before? Yes No How? __________________ _

CHARACTER OF YOUR PAIN PLEASE CHECK ALL THAT APPLY & THE LOCATION IT OCCURS:

Continuous (all day): Dull Sharp Throbbing Shooting

Hot/Burning Tingling

Where?

Intermittent (on & off): Dull Sharp

Throbbing Shooting


Where? Occasionally: Dull Sharp

Throbbing Shooting


Where?

What makes your pain worse? Sitting Standing

Laying Flat

Bending Forward How long can you currently:

What makes your pain better?

Sit min

Walk

_____ Laying Down _____ Heat

min

Stand

Run

_____ Walking __ PT

Aching Radiating

Num

Aching

Radiating

Num

Aching

Radiating

Num

Walking

Driving

Bending Backwards

min

min

___ Ice

__ CHIRO

_____ Massage _____ Medications Other: __ _

DOES THE PAIN LIMIT YOUR ACTIVITIES OF DAILY LIVING? Yes No

If yes, what percent of the day? 10% 25% 50% 75% 100%

What can you NOT do or have difficulty doing now?

Self care: Showering Brushing Hair Brushing Teeth Putting on cloths

Physical Activity: Climbing Stairs Walking Standing Sitting Exercise

Hand Activity: Lifting Pulling/Pushing Grasping Turning Pages Holding things

Travel: Driving a car Handling luggage Pain with sitting Pain with bumps in the road

Sexual Function: Performing Erection Orgasm Enjoying Pain During/ After

DOES THE PAIN KEEP YOU FROM DOING THE EXERCISES THAT YOU WANT? Yes No If yes, please describe:

DOES THE PAIN AFFECT YOUR SLEEP? Yes No If yes, please describe your sleeping habits:

WHAT TREATMENTS HAVE YOU HAD? DATES DONE DID THIS HELP?

Physical Therapy Yes No

Chiropractic Therapy Yes No

Acupuncture Yes No

Osteopathic Manual Yes No

Trigger Point Injections Yes No

Joint Injections Yes No

Epidural/Facet Injection Yes No

Surgeries Yes No

Surgeries Yes No

Other Yes No

Other Yes No

Other Yes No

Patient name (print) Date

Patient signature or Legally Authorized Representative



Irvine, CA 92614 (T) 949.535.2322 (F) 949.535.2330

The California Boards for Osteopaths (DO) and Chiropractors (DC) (government licensing agency) requires all DOs and DCs to obtain written informed consent from their patients to receive care.

OSTEOPATHIC AND CHIROPRACTIC MANUAL MEDICINE Osteopathic and Chiropractic manual medicine is a form of treatment based on the concept that the structure of the human body influences the function. The goal of treatment is to improve the body's structure. This in turn, enables the body to function at a higher level of health. This usually reduces the amount of pain experienced by the patient as well as the increased ability of the body to fight disease (i.e. stimulate the immune system). As in most forms of medical treatment, no specific results can be guaranteed.

TREATMENT PROGRAM The physician will ask questions; perform a physical examination, which includes the musculoskeletal system in order to detect any somatic dysfunction (abnormalities such as tenderness, asymmetry, restricted range of motion and abnormal changes in the muscles, joints, bones, connective tissue, etc.). The physician's goal is to locate then reduce or resolve this somatic dysfunction. Techniques range from a very light touch to more increased pressure.

Other recommendations may be given to help the dysfunction, such as diet, exercise, or stretching regimens.

TREATMENT RISKS Patients rarely experience side effects as a result of Osteopathic or Chiropractic manual medicine. They are considered one of the safest and most non-invasive forms of medical treatment. Most side effects occur from other forceful types of manipulation. These are not utilized, nor does the our doctors generate any treatments with high forceful quick movement. However, for purposes of disclosure, the following side effects have been reported from all forms of manual medicine:

Fractures: When patients have underlying conditions that weaken bones, like osteoporosis, they may be susceptible to fracture. It is important to notify your doctor if you have been diagnosed with a bone weakening disease or condition. If you doctor detects any such condition while you are under care, you will be informed and your treatment plan will be modified to minimize risk of fracture.

Disc herniation or prolapsed: Spinal disc conditions like bulges or herniations may worsen even with manual care. Our office have highly trained and experienced doctors in treating disc injuries so it is important to notify your doctor if symptoms change or worsen. Other risks associated with osteopathic or chiropractic treatment include slight muscle/tendon strains with stretching procedures of these tissues.

I understand that the practice of osteopathy and/ or chiropractic, like the practice of all healing arts, is not an exact science, and I acknowledge that no guarantee can be given as to the results or outcome of my care. It is not reasonable to expect my doctor to be able to anticipate or explain all possible risks and complications of a given procedure on any particular visit, and I wish to rely on the doctor to exercise professional judgment during the course of any procedure which he feels at the time to be in my best interest.

I understand that there are other forms of treatment, including drugs and surgery, which could possibly be treatment options for my condition, clinical/ therapeutic nutrition is part of my care, I understand that it may consist of but not be limited to the following: Nutritional supplementation of vitamins, minerals, amino acids, and other nutritional or therapeutic substances.

Homeopathic medicine: the use of highly dilute quantities of naturally occurring plants, animals, and minerals to gently simulate the body's healing responses.

Lifestyle counseling and hygiene: diet therapy, fasting elimination diets, promotion ofwellness to include recommendations for exercise, stress reduction and balancing of work and social activities.

Thank you for taking the time to read this agreement. We understand that you have come here to seek specialized treatment and we will endeavor to assist you in a speedy recovery.

If you have any concerns or specific questions regarding the risks or benefits of treatment, please ask the physician before signing the consent form.

CONSENT TO TREATMENT I authorize Restoration Healthcare, Inc., its physicians, contracted practitioners, staff and other individuals involved in my care to examine me and perform any tests and/or treatments that may be helpful to care for my injury or illness. I understand that information in my chart will be available to any Restoration Healthcare, Inc. practitioner from whom I may seek treatment. I understand that the practitioner responsible for this care will explain the reasons for any tests and treatments, as well as the benefits, the most common risks, and alternative courses of treatment. I also understand that I have the right to refuse any suggested examinations, tests, or treatment.

I consent to information regarding my care being used, on a blinded, non-identifiable basis only, in Restoration Healthcare's research, outcomes assessment and peer review programs.

I understand that urgent/emergency problems occurring after hours should be addresses to my primary care provider, who may or may not be located at Restoration Healthcare, Inc.

I understand and agree that my medical record may be released to other providers and organizations for the purpose of continuing care, payment for services or health center operations.

PAYMENT Payment is expected at time of service and can be made by cash, check, and money order. We also accept American Express, Discover, Visa or MasterCard. We will provide you with an itemized receipt for you to submit to your insurance company for reimbursement, if the services that you receive are covered by your policy.

I agree to pay any services I receive from a Restoration Healthcare, Inc. practitioner and I understand that payment is expected at time of service. I understand that if I do not come for my scheduled appointment, or if I cancel or reschedule my appointment giving less than 24 hours notice, I may be held responsible for the fee for the missed appointment. I further agree and understand that this office can only code my visit with a diagnosis that was encountered and documented in my medical record.

Patient name (print) Date

Signature of patient or legal guardian

PHYSICIAN-PATIENT ARBITRATION AGREEMENT Article 1: A&:reement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence g1ving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician's partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them. must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.

The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure Section 1283.05, however, depositions may be taken without prior approval of the neutral arbitrator.

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:

Effective as of the date of first medical services Patient's or Patient Representative's Initials

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

By: -----------------------------Physician's or Authorized Representative's Signature

Print or Stamp Name of Physician, Medical Group, or Association Name

Date

BY=-------------------------------Patient's or Patient Representative's Signature Date

BY=----------------------------------------Print Patient's Name

(If Representative, Print Name and Relationship to Patient)

A c:ian~ri f"nnv nf +hie: rinr11mont ic- tn ha aiuon tn tho P~tiont "-rinin~l i<- tn h,..,. fif,..l'f in c ..... ;,..,.,p ... """'~: ...... 1 ............. .-.~ ...

RESTORATION HEALTHCARE


Irvine, CA 92614 (T) 949.535.2322 (F) 949.535.2330

IF YOU WILL BE USING INSURANCE BENEFITS TO COVER SERVICES, PLEASE COMPLETE AND SIGN BELOW:

Insurance Company: ______________ Group/Policy#: _______ _

Medicare: Yes/ No Medicare#: ___________ Retirement Date: _______ _

Name of Insured (First, Middle, Last):----------------------

Relationship to Insured: ___________ SSN of Insured: __________ _

I hereby instruct the insurance company listed above to pay by check made out to and mailed directly to the following address. If my current policy prohibits direct payment to doctor, then I hereby also instruct and direct you to make out the check to me and mail it as follows:


Irvine, CA 92614

For the professional or medical expense-benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered. This is a DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay in current manner any balance and/ or Co-pay of said professional service charges over and above the insurance payment. I further understand that I will be responsible for payment to any other facilities and/or health care providers that I may be referred to by Restoration Healthcare, Inc. and any emergency transporting that may be required thereto. I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney involved in the case.

Patient or Insured Signature: ________________ Date: ________ _

IF YOU DO NOT HAVE INSURANCE THAT COVERS SERVICES, PLEASE READ AND SIGN BELOW:

I hereby acknowledge that I have no insurance that covers services, and I understand that all services are payable when treatment is rendered. I further understand that I will be responsible for payment to any other facilities and/or health care providers that I may be referred to by Restoration healthcare, Inc. and any emergency transporting that may be required thereto.

I further acknowledge that the fees I am paying are discounted from the usual and customary fees for services and the discounted fees I am paying are being applied to the usual fees. In the event that my insurance status changes andjor I elect to use a third party payer, the standard fees may apply.

Patient/ Guardian Signature: _______________ Date: ________ _

RESTORATION Restoration Healthcare, Inc.

18818 Teller Ave. Suite 170 Irvine, CA 92614

(T) 949.535.2322 (F) 949.535.2330

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Our practice is dedicated, and we are required by applicable federal and state laws, to maintain the privacy of your health information. These laws also require us to provide you with this notice of our privacy practices, and to inform you of your rights, and our obligations, concerning your health information. We are required to follow the privacy practices described below while this notice is in effect. This notice is effective as of April 14th, 2003, and will remain in effect until we replace it.

CHANGES TO NOTICE:

We reserve the right to change this notice and the privacy practices described below at any time in accordance with applicable law. Prior to making significant changes to our privacy practices, we will alter this notice to reflect the changes, and make this revised notice available to you on request. Any changes we make to our privacy practices and/or this notice may be applicable to health information created or received by us prior to the date of the changes.

You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using this information listed at the end of this notice.

PERMITTED USES AND DISCLOSURES OF HEALTH INFORMATION:

A. TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS: You should be aware that during the course of our relationship with you we will likely use and disclose health information about you for treatment, payment, and healthcare operations. Examples of these activities are as follows:

Treatment: We may use or disclose your health information to a physician or other health care provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, and other business operations.

B. AUTHORIZATIONS: You may specifically authorize us to use your health information for any purpose or to disclose your health information to anyone, by submitting such an authorization in writing. Upon receiving an authorization from you in writing we may use or disclose your health information in accordance with that authorization. You may revoke an authorization at any time by notifying us in

writing. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those permitted by this notice.

C. DISCLOSURES TO FAMILY AND PERSONAL REPRESENTATIVES: We must disclose your health information to you, as described in the Patient Rights section of this notice. Such disclosures will be made to any of your personal representatives appropriately authorized to have access and control of your health information. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare only if authorized to do so. In the event of your incapacity or in emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare.

D. MARKETING: We will not use your health information for marketing communications without your written authorization, unless allowed by HIPAA.

E. USES OR DISCLOSURES REQUIRED BY LAW: We may use or disclose your health information when we are required to do so by law, including for public health reasons (e.g., disease reporting). In some instances, and in accordance with applicable law, we may be required to disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes.

F. PATIENT AND THIRD PARTY PROTECTION: Only as permitted by law, may we disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

G. LAW ENFORCEMENT/NATIONAL SECURITY: Under certain drcumstances we may disclose health information relating to members of the Armed Forces to military authorities. Under certain circumstances we may also disclose health information relating to inmates or patients to correctional institutions or law enforcement personnel having lawful custody or those individuals. We may disclose health information in response to judicial proceedings and law enforcement inquiries as permitted by law and to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities.

H. APPOINTMENT REMINDERS: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS

A. ACCESS TO RECORDS: Upon submission of a written request to us, you have the right to review or receive copies of your health information, with limited exceptions. You may obtain a form to request access by using the contact information listed at the end of this notice. You may request that we provide copies in a format other than photocopies and we will use this format you request if it is readily available. We will charge you a reasonable cost-based fee relating to the production of such copies. If you request copies, we will charge you reasonable costs of labor associated with making copies including twenty-five (25) cents per page for copies or fifty (50) cents per page from microfilm, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a reasonable cost-based fee for providing your health information in that format If you prefer, we will prepare a summary or an explanation of your health information for a fee. Inspection of records will be allowed during normal business hours per appointment. A fee for locating, making the file available

and being present during the review may be charged. Contact us using the information list at the end of this notice if you are interested in receiving a summary of your information instead of copies.

B. ACCOUNTING OF CERTAIN DISCLOSURES: Upon written request, you have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, and other activities authorized by you, for the last 6 years, but not before April14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

C. RESTRICTIONS AND ALTERNATIVE COMMUNICATIONS: You have the right to request that we place additional restrictions on our use or disclosure of your health information for treatment, payment, and healthcare operations purposes. Depending on the circumstances of your request we may, or may not agree to those restrictions. If we do agree to your requested restrictions we must abide by those restrictions, except in emergency treatment scenarios. You have the right to request that we communicate with you about your health information by alternative means or to alternative locations (e.g., at your place of business rather than at your home). Such requests must be made in writing, must specify the alternative means or location, and must provide satisfactory explanation how payments will be handled under the alternative means or location you request

D. AMENDMENTS TO RECORDS: You have the right to request that we amend your health information. Such requests must be made in writing, and must explain why the information should be amended. These amendments will add to what is already in your file. Information that already exists will not be removed or altered. We may deny your request under certain circumstances.

E. ELECTRONIC NOTICES: If you receive this notice on our website or by electronic mail (e-mail), you are entitled to receive this notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made or any decisions we may make regarding the use, disclosure, or access to your health information, you may complain to us using the contact information listed below. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file such a complaint upon request

We support your right to privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Please direct any of your questions or complaints to:


Irvine, CA 92614 (T) 949.535.2322 (F) 949.535.2330

Copyright© 2002 Brown Rudnick eSolutions, LLC. All Rights Reserved



Irvine, CA 92614 (T) 949.535.2322 (F) 949.535.2330

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received the Notice of Privacy Practices of Restoration Healthcare, Inc. which describes the practice's policies and procedures regarding the use and disclosure of any of my Protected Health Information created, received, or maintained by the practice. I have had the summary explained to me and understand the Practice will explain any questions I have regarding the complete privacy notice.

Signature:--------------------- Date: _________ _

Printed Name:----- ---------------

FOR OFFICE USE ONLY IF NOTICE NOT APPROVED TO PATIENT

The Practice has made a good-faith effort to obtain an acknowledgement of the patient's receipt of our Notice of Privacy Practices. In spite of these efforts, the Practice has been unable to obtain a signed acknowledgement of receipt for the following reasons(s):

D Patient unavailable 0 Patient physical unable

D Patient unwilling 0 Other (describe):

On an effort to obtain the patient's acknowledgement, the Practice has attempted to provide the patient with a Notice of Privacy Practices in the following manner( s):

D Personally D Mail

D Phone follow-up D Other (describe):

Patient Name:-----------------------------

Physician Signature: ________________ Date: __________ _



Irvine, CA 92614 (T) 949.535.2322 (F) 949.535.2330

AUTHORIZATION FOR THE RELASE OF MEDICAL INFORMATION Please read all information and instructions before completing and signing the authorization form.

Patient's Name:------------------- Birth date: ______ _ (Please Print) Last First Ml

Are medical records filed under another name? _________ Phone Number: ________ _

INFORAMTION TO BE RELEASED BY: INFORMATION TO BE RELEASED TO: REQUEST MUST HAVE COMPLETE ADDRESS OR FAX NUMBER REQUEST MUST HAVE COMPLETE ADDRESS OR FAX

NUMBER

Organization/Person Name Dr. MaryS. Raleigh, D.O. Restoration Healthcare, Inc.

Street Address City, State, Zip 18818 Teller Ave. Suite 170

I Irvine, CA 92614 Phone Fax (T) 949.535.2322 (F) 949.535.2330

TYPE OF MEDICAL INFORMATION REQUESTED: 0 Complete medical record abstract (includes 3 years of chart notes, most recent labsjpathology & diagnostic imaging reports)

0 Cancer Partnership records

0 Radiology/ Diagnostic Imaging (CO/Films)

0 Mammogram Diagnostic Imaging (CO/Films)

0 Echocardiograms 0 Pharmacy

0 Behavioral Health records only 0 My health information relating only to the following treatment or condition: ____________ _

0 My health information only for the following date(s): ---------------------0 Other:

REASON FOR REQUEST (circle):

Personal Transfer of Care Disability Insurance Legal Review Continuing Care

I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse or self-paid services. You are hereby specifically authorized to release all information or medical records relating to such diagnosis, testing, or treatment, unless specifically excluded below.

MINORS AGE 13-17: A minor patient's signature is required in order to relase the following information: (1) conditions relating to the minors reproductive care including, but not limited to : contraception, pregnancy, and pregnancy termination, sterilization, and sexually transmitted diseases (age 14 and older), (2) alcohol andjor drug abuse (age 13 and older), and (3) mental health conditions (age 13 and older).

I hereby consent to the release of the specified information relating to diagnosis, testing or treatment to the person or entity named above. I understand that such information cannot be released without my informed consent. I acknowledge I have fully reviewed and understand the contents of this authorization form. My signature below indicates that I hereby agree to and authorize the release of patient health information to the above named person or organization. You have the right to revoke or cancel this authorization, in writing, at any time. I understand that I do not have to sign this authorization in order to get health care benefits (treatment, payment, enrollment, or eligibility for benefits).

THERE MAY BE A CHARGE FOR COPIES OF YOUR MEDICAL RECORD UNLESS YOUR COPIES ARE BEING SENT TO ANOTHER PHYSICIAN OR HEATH CARE FACILITY

Signature of patient Date

Signature of parent or legal guardian Date

restoration healthcare, inc. restoration 18818tellerave...

Documents