General Information

Referral

Insurance information

General Information

2657 Batchelder Street Brooklyn, NY 11235 Phone (718)332-3401 Fax (646)7198631 Email: dr.salemdpt@gmail.com

Current/Past Health Medical History

INTEGRATED REHAB & PHYSICAL THERAPY P.C.

2657 Batchelder Street Brooklyn, NY 11235 phone (718) 332-3401 Fax (646) 719-8631 Email: dr.salempt@gmail.com

General Consent, Authorization and Release

General Consent: I am the patient named below or the person authorized to consent medical care for the patient (“Surrogate“). I authorize Integrated Rehab & Physical Therapy P.C. (“Practice”) and the providers and other employees on its staff, to perform upon me/the patient, such examinations, diagnostic and other medical procedures or treatments, as may be necessary. I acknowledge that no guarantee have been made as to the results of such procedures or treatments.

Release of Personal Information I authorize the practice to disclose all or any part of my medical record to the extent permitted by law, including information relation to treatment for behavioral health conditions, drug or alcohol use or HIV or AIDS, for the purpose of determining coverage for payments by the third party payer which may be liable for payment for the practice and/or professional services. I also authorize the practice to use and disclose my personal health information to treat me and arrange for my medical care, to seek and receive payment for services given to me and for the operations of the practice.

Assignment of Insurance Benefits I authorize payment directly to the practice for all charges otherwise payable to me.

Agreement to pay charges not covered by Insurance I acknowledge that I am financially responsible to pay the practice and its providers for all charges not covered by my insurance. I agree to pay all such charges as the bills are presented.

Acknowledgement of Receipt of Notice of Privacy Practice I acknowledge that I have been given a copy of the practice’s notice of the privacy practices and have therefore been advised of how health information about me may be used and disclosed by the practice, and how I may obtain access to and control this information.

By signing below, I am confirming that I have read to me in my chosen language, and that I have been given the opportunity to ask questions it before signing.

HIPPA NOTICE OF PRIVACY PRACTICES

PURPOSE: THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE DISCLOSED AND HOW YOU CN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THIS NOTICE GOES INTO EFFECT ON APRIL 14, 2003 AND REMAINS IN EFFECT UNTIL WE REPLACE IT.

1.)  OUR PLEDGE REGARDING MEDICAL INFORMATION The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you received at our practice. We need the record to provide you with quality care and comply with certain legal requirements. This notice will tell you about the ways that we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.

2.) OUR LEGAL DUTY
a. Law Requires Us to:
i. Keep medical information private.
ii. Give you this notice describing our legal duties, privacy and your rights regarding medical information.
iii. Follow the terms of this notice that is now in effect.
  b. We Have The Right To:
i. Change the privacy practices and terms of tis notice at any time, provided that the law permits the    changes.
ii. Make the changes in our policy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before that changes were made.

3.) USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION The following section describes the different ways that we use and disclose medical information. Not every use of disclosure will be listed. However we have listed all the ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purposes not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us confirming receipt of written authorization.
a.       For Treatment: The HIPAA regulation permits nearly unlimited sharing of information among providers who are involved in a patient’s treatment. Users and disclosures of information commonly include collection of information from the patient by a physical or other medical practitioner for: performing diagnostic tests and reviewing results, consulting with other providers on diagnosis or treatment, referring a patient to another provider, and transmitting information to another provider such as phoning prescription into a pharmacy or placing an order for an ice machine, brace, or other durable medical equipment.
b.    For Payment: We are permitted to disclose to the patient’s health plan, any information needed to process a claim. For           example : to determine whether a patient is eligible for coverage under a health plan, to determine whether tests or services are covered under a health plan, to submit a claim or inquire about the status of a claim, to process payment or         claims remittances, and process credit card transactions.
c.     For Health Care Operations: Staff may use and disclose only the “minimum necessary” information for the task at hand. This includes:             maintenance of medical records, maintenance of accounting records, quality assurance activities, staff performance evaluations, conducting financial and management audits, investigating complaints, supporting legal activities, resolving grievances, and general business management.
d.    For Law Enforcement: Your health information may be disclosed to law enforcement agencies to facilitate investigations, inspections, or mandated reporting. Your health information may be disclosed to public health agencies as required by law.

4.) HIPAA NOTICE OF PRIVACY PRACTICES Your health information may be used to send you information that you find interesting on the treatment and    management of your medical condition.

5.) INDIVIDUAL RIGHTS You have the right to request restrictions on the use and disclosure of your protected health information, the right to receive confidential communications regarding your treatment and condition, the right to inspect and copy your health information, the right to amend or submit corrections to your health information, and the right to receive a printed copy of this notice. As permitted by federal regulations, we require that a request to a copy or review protected information be submitted in writing. If you would like to submit a comment about our privacy practices, you may do so by sending a letter outlining your concerns. If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to: HPAA Privacy Official; Premier Physical therapy; 1536 Third Ave., FL 5; New York, NY 10028.

6.) ACKNOWLEDGEMENT OF FORM I have received the Notice of Privacy Practices and I have been provided the opportunity to review the contents.