New Patient Packet

COLLEYVILLE MEDICAL CLINIC

PATIENT INFORMATION

Please print and use black or blue ink

PERSONAL INFORMATION

Last Name MI First Name

Date of Birth Sex M F SSN

RESIDENTIAL INFORMATION

Address

City State ZIP

Home Cell FAX

E-mail

EMERGENCY CONTACT

Name

Address

City State ZIP

Cell Work

PREFERRED PHARMACY

Name

Address

City State ZIP

Telephone Fax

I understand that that any information I provide is strictly confidential and will be used by Colleyville Medical Clinic for business purposes only.

COLLEYVILLE MEDICAL CLINIC

CONSENT FOR TREATMENT

CONSENT FOR TREATMENT (please initial)

I consent to the administration and performance of all treatments or procedures by members of the Colleyville Medical Clinic (CMC) staff, which in the judgment of the treating practitioner may be considered necessary or advisable for the treatment of the condition for which I am seeking care. I understand that the services provided by Colleyville Medical Clinic do not constitute an exact science and acknowledge that no guarantees have been made or implied regarding my treatment or outcome.

DISCLOSURE (please initial)

I understand that my care may be managed by a physician who is an independent contractor providing services for CMC. I understand that any services I may receive from the medical staff at CMC does not create or constitute a traditional Primary Care Practitioner relationship between any physician practicing with CMC and myself, and that I am responsible for obtaining any specialty care which may be recommended. I also acknowledge that CMC will not provide after-hours care or physician call coverage, and I agree to seek emergency or urgent medical care for any condition for which I feel the need arises.

CONFIDENTIALITY STATEMENT (please initial)

I understand that, in accordance with State and Federal law, all Personal Health Information produced or provided by patients shall be maintained on an electronic health record in strict confidentiality, and that CMC does not sell any personal health information. I understand that at times information pertaining to my condition or treatment may need to be shared with other medical professionals in order to facilitate future care for myself, and that my records may be transmitted via voice, mail, or fax to such professionals. I acknowledge that I may request a copy of all or part of my CMC information file at any time, and agree to pay a reasonable fee for such copies at the time of my request. I have been given a copy of the HIPAA notice as prepared by CMC.

RELEASE OF RESPONSIBILITY FOR VALUABLES (please initial)

I acknowledge that CMC is not liable for any loss or theft of my personal property, whether a patient, visitor, guest, agent or employee of CMC causes such loss or theft.

APPOINTMENT CANCELLATION POLICY (please initial)

I acknowledge that I may cancel a scheduled appointment without charge at any time before the close of business on the business day immediately preceding my appointment. I understand that if I cancel my appointment on the day it is scheduled or miss my appointment altogether, I will be charged a $50.00 fee.

NOTICE ON INSURANCE & PAYMENT GUARANTEE (please initial)

In order to provide services at reasonable rates, CMC does not accept any form of health insurance reimbursement or “co-pays,” and does not belong to or participate in any Health Maintenance, Preferred Provider, Medicare, Medicaid, or any other insurance plans or networks.

I assume full responsibility for and agree to pay all costs, charges, and fees incurred for the services provided by CMC and its affiliates, and I understand that all fees are due in full at the time services are rendered. In the event that external collection services become necessary to obtain payment, I agree to pay all such collection agency and attorney fees, as well as court costs.

I understand that it is my responsibility to collect any reimbursement or credit that I feel may be due from my health insurance carrier or third party administrator, and CMC does not guarantee, promise or otherwise warrant that I will be successful in any such endeavors.

Printed Name

COLLEYVILLE MEDICAL CLINIC

ARBITRATION AGREEMENT

AGREEMENT TO ARBITRATE – This is an Agreement between Colleyville Medical Clinic and the Patient undersigned below (hereafter collectively referred to as “the parties”) that any dispute regarding medical malpractice (whether any professional services rendered under the Colleyville Medical Clinic Consent for Treatment were unnecessary, unauthorized, or were rendered improperly, negligently or incompetently) will be determined by submission to binding arbitration as provided by state and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitration proceedings. It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration. By entering into this Agreement, the parties choose to relinquish their constitutional right to have any such dispute decided in a court of law before a jury, and instead hereby accept the use of arbitration.

ALL CLAIMS MUST BE ARBITRATED – In considering disputes arising out of or relating to treatment or services provided by Colleyville Medical Clinic, it is the intention of the parties that this Agreement (1) shall bind all parties as to all claims, including claims brought by any heirs or past, present or future spouse(s) of the Patient in relation to all claims, including loss of consortium; (2) is intended to bind any and all claims brought by any children of the Patient, whether living or unborn at the time of the occurrence giving rise to said claim(s); and (3) is intended to bind the Patient and all employees, agents, or health care providers who now or in the future treat the Patient while employed by or affiliated with Colleyville Medical Clinic. Further, the parties agree that all claims against Colleyville Medical Clinic, its health care providers, associates, association, corporation, partnership, employees, agents and estate for monetary damages including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages must be arbitrated.

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 both parties’ arbitrators within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay said 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, witness fees, or other expenses incurred by a party for said party’s own benefit.

Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that 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 state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement.

GENERAL PROVISION – 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 legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence.

REVOCATION – This agreement may be revoked by the Patient by providing written notice delivered to Colleyville Medical Clinic within 30 days of Signature, and if not revoked will govern all professional services received by the Patient and all other disputes between the parties.

SEVERABILITY – 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.

PATIENT NAME (print)

Effective Date: April 14, 2003

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We understand and respect that information about you and your health is personal. By law, Colleyville Medical Clinic is required to maintain the privacy of your health information, to follow the terms of this Notice, and to provide you with this notice of our legal duties and privacy practices with respect to your health information. For your convenience, you may print a paper copy of this notice for your records at any time.

How Colleyville Medical Clinic May Use or Disclose Your Health Information

Colleyville Medical Clinic protects the privacy of your health information. For some activities, we must have your written authorization to use or disclose your health information. However, the law permits Colleyville Medical Clinic to use or disclose your health information for the following purposes without your authorization:

As Required by Law: We will disclose health information about you when required to do so by Federal and State Law.

To Avert a Serious Threat to Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure would be only to a person or agency able to help prevent the threat.

Public Health Risks: We may disclose health information about you for public health activities. Those activities generally include the following: (1) to prevent or control disease, injury or disability; (2) to report reactions to medications or problems with products; (3) to notify people of product recalls; (4) to notify a person that may be exposed to a disease or may be at risk of spreading a disease; (5) to notify the appropriate government authority if we believe a person has been the victim of abuse, neglect, or domestic violence.

Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law.

Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose health information about you in response to a court or administrative order. We may disclose information about you in response to a subpoena, or other lawful process, but only if efforts have been made to tell you about the request.

For Specific Government Functions: We may disclose health information for the following specific government functions (1) health information of military personnel, as required by military authorities ; (2) health information of inmates to a correctional institution or law enforcement official; (3) in response to a request from law enforcement, if certain conditions are satisfied; and (4) for national security reasons.

For Treatment: Information obtained by Colleyville Medical Clinic may be shared or communicated with your physician and/or other health care professionals who are involved in your care.

For Company Operations: We may use and disclose health information about you for company operations.

Unless you provide us with alternative instructions, we may send reminders and other materials related to your health care to your home. These uses and disclosures are necessary to ensure that you receive quality service.

When Colleyville Medical Clinic May NOT Use or Disclose Your Health Information

Except as described in the Notice, Colleyville Medical Clinic will not use or disclose your health information without your written authorization. If you do authorize Colleyville Medical Clinic to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

You Have the Following Rights With Respect to Your Health Information

You have the right to request restrictions on certain uses and disclosures of your health information. We are not required to agree to the restrictions that you request. If we do agree to any restrictions, we will put the agreement in writing and follow it except in emergency situations. We cannot agree to limit the disclosure of any information that is required by law.

You have the right to inspect and copy your health information as long as Colleyville Medical Clinic maintains the health information. To inspect a copy of your records, you must submit a request in writing. We may charge a fee for the costs of copying, mailing, or supplies necessary to grant your request. In certain limited situations, we may deny your request. If your request is denied, you may request that the denial be reviewed.

You have the right to request that we amend or correct any health information that is incorrect or incomplete. To request an amendment, you must submit a request in writing along with the reason for the request. We are not required to amend health information that is accurate and complete.

You have the right to receive an accounting of disclosure of your health information we have made after April 14, 2003 for purposes other than disclosures for (1) payment, treatment, or health care operations ; (2) to you or based upon your authorization; or (3) for certain government functions. You must submit your request in writing.

You may request communication of your health information by alternative means or at alternative locations. You may request that we contact you only in writing or at a different residence or post office box. To request confidential communication of your health information, you must submit a written request. We will accommodate all reasonable requests.

Changes to this Notice of Privacy Practices

Colleyville Medical Clinic reserves the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have about you as well as any information we receive in the future. Any revised Notice will be posted at the business and posted on our website. Upon request we will provide a revised Notice to you or you may print one for your records.

For More Information or to Report a Problem

If you have questions or would like additional information about our company's privacy practices, you may contact:

Compliance Officer
Colleyville Medical Clinic
6400 Colleyville Blvd.
Colleyville, TX 76034

or by email to: info@colleyvillemedclinic.com. If you believe your privacy rights have been violated, you can file a complaint with the Compliance Officer at the above address, or with the Secretary of Health and Human Services.

There will be no retaliation for filing a complaint.