Patient Intake Form

The department of health and human services has established a "Privacy Rule" to help insure that personal information is protected for privacy, the Privacy rule to obtain their patients' consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations As our patient we want you to know that we respect the privacy of your personal medical information and will do all we can to secure and protect that privacy, We strive to always take reasonable precautions to protect your privacy, When it is appropriate and necessary, we provide minimum information to only those we feel are in need of your health care information, treatment, payment and health

We also want you to know that we support your full access to your own personal medical records, We may have indirect treatment relationships with You (such as laboratories that only interact with health care providers not the patient themselves) and may have to disclose personal health care information for purposes of treatment, payment, or health care operations, These entities are most often not required to obtain patient consent

You may refuse to consent to use or discloser of your person.al health information, but this must be in writing, under this  law, we have the right to refuse to treat you should you refuse to disclose your personal health information (PHI),if you choose to give consent in this document, at some future time you may request, to reuse all or part of you (PHI)You may not receive actions that have already been taken which relied on this or previously signed consent If you have any objections to this form, please ask to speak with our HIPM compliance officer. .

You have the right to review your privacy notice, to request restrictions and revoke consents in writing after you have reviewed our privacy notice.

Patient  medication   history  is a list of prescriptions   that healthcare   providers  have  prescribed   for you.  A variety  of sources,  including  pharmacies   and health  insurers,  contribute  to the collection  of this history.

The collected  information   is stored  in the practice  electronic  medical  record  system  and becomes  part of your personal  medical  record.  Medication   history  is very  important  in helping  providers  treat your  symptoms   and/or illness properly  and avoid potentially   dangerous  drug  interactions.

It is very important  that you and your provider  discuss  all your medications   in order  to ensure  that your recorded medication   history  is 100% accurate.   Some pharmacies   do not make  prescription   history  information   available, and your  medication  history  might  not include  drugs  purchased  without  using your  health  insurance.

Also over-the-counter    drugs,  supplements,   or herbal  remedies  that you take on your  own may not be included. I give my permission   to allow  my healthcare  provider  to obtain  my medication   history  from

my pharmacy,  my health  plans,  and my other healthcare  providers.