3053 Center Point Rd. NE, Cedar Rapids, IA 52402
Podiatry Associates, PC
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I acknowledge that I was provided a summary copy of the 'Notice of Privacy Practices' and that I have read (or had the opportunity to), if I so chose.
FOR OFFICE USE ONLY:
We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because
Individual refused to sign
Communication barriers prohibited obtaining the acknowledgment
ASSIGNMENT OF RELEASE
I hereby give my permission to Podiatry Associates PC and /or Family Foot Care, PLC to release information requested by my insurance company acquired in the course of my examination and treatment. I also give permission to Dr. Beevers, Dr. Dolphin, Dr. Kukla, Dr. Orosz, Dr. Parker, and Dr. Tanner to administer treatment and perform such general procedures as he may deem necessary in the diagnosis and/or treatment of my foot condition.
Many companies have fixed allowances or percentages based on your contract with them, not with our office.
I understand I am responsible for any co-pays, deductibles, and non-covered services at the time of the service. I also understand I am responsible for any balances after insurance for whatever the reason.
I further understand that by providing my wireless/cell phone number, I am here by granting you, your agents or independent contractor, my consent to receive calls on my wireless/cell phone number for billing and debt collection purposes.
3053 Center Point Rd. N.E., Suite 8 • Cedar Rapids, Iowa 52402-4049 • Phone: (319) 365-6973 • Fax (319) 365-69743359 Center Point Rd. NE, Cedar Rapids, IA 52402 (319) 393-4343 • 3200 F Ave. NW, Cedar Rapids, IA 52405 (319) 362-1947208 East Main St., Anamosa, IA 52205 (319) 462-3709 • 717 East Main St., Manchester, IA 52057 (563) 927-2944175 Hwy. 965, Suite 1, North Liberty, IA 52317 (319) 665-3733 • 28 West Charles St., Oelwein, IA 50662 (319) 283-1373
Podiatry Associates, PC and Family Foot Care Center
Are you diabetic?
If yes, give date of your last blood wont up?
Do you get the flu shot?
Current Shoe size
Do you currently smoke?
Have you ever smoked:
Is this problem due to m injury or trauma (if so, please explain)
Describe your foot/ankle pain:
Please check any past or present conditions that apply to you:
Do you have any allergies to medicines or tape:
PODIATRY ASSOCTATPS, PC.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES gm MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND NOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US
OUR LEGAL DUTY
We are required by applicable federal and 'state laws to maintain the privacy of your protected health information. We are also required to give you this notice about our privacy practices, our legal duties and your rights concerning your protected health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect April 14, 2001, and will remain in effect until we replies it.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided that such amps am permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all protected health information that we maintain, including medical information we created or received before we made 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 the information listed at the end of this notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We will use and disclose your protected health Information about you for treatment, payment and health care operation For example:
Treatment: We may use or disclose your health information to a physicist or other healthcare provider providing treatment to you.
Payments: Your protected health information will be used as needed, be obtain payment for your health care services.
Health Care Operation: We may use or disclose, as needed, your protected health information in order to conduct certain business and operational activities. These activities include, but are not limited to, quality assessments activities, employee review activities, training of student, licensing and conductor' or arranging for other business activities.
Your Authorization: In addition to our use of your health information for treatment payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. 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 described in this Notice.
Others Involved in Your Health Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgement: We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.
Marketing health-Related Service,: We will not use your health information for marketing communications without your written authorization.
Abuse or Neglect We may disclose your health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence & to the governmental entity or agency authorized to receive such information. This disclosure will he made consistent with the requirements of applicable federal and state laws.
Required by Law: We may use or disclose your health information when we we required to do so by law.
Law Enforcement: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and either national security activities. We may disclose to correctional institution or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.