Patient Registration Form - ProSites, Inc.c1-preview.prosites.com/83505/wy/docs/New Patient... · care. For example, a personal representative may include the parent or guardian of

Patient Registration Form

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Thank you for choosing our office. In order to serve you properly, we will need the following information. Please print. All information is strictly confidential.

PATIENT NAME _____________________________________________ PRIMARY LANGUAGE SPOKEN _________________ (LAST) (FIRST) (MI)

ADDRESS ______________________________________________________________________________________________________ (STREET) (APT.) (CITY) (STATE) (ZIP)

HOME PHONE (_____)_________________ WORK PHONE (_____) __________________ EXT. _____________

CELL PHONE (_____)_________________ OTHER (_____)___________________

EMPLOYER _____________________________ EMP STATUS: FT PT STUDENT( FT or PT ) RETIRED NOT EMPLOYED

SEX: MALE FEMALE BIRTHDATE _______ / _______ / _________ SSN __________________________

E-MAIL _________________________________ I agree to communicate with my provider’s office via e-mail: YES NO

PRIMARY CARE PHYSICIAN_____________________________________ DRIVER’S LICENSE # _________________________

RACE: AFRICAN AMERICAN ASIAN CAUCASIAN NATIVE AMERICAN OR ALASKA NATIVE NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER OTHER_______________ DECLINE TO STATE

ETHNICITY: HISPANIC/LATINO NON-HISPANIC/NON-LATINO DECLINE TO STATE

RELIGIOUS PREFERENCE: _______________________________________ DECLINE TO STATE

MARITAL STATUS: SINGLE MARRIED LIFE PARTNER WIDOWED DIVORCED SEPARATED

RESPONSIBLE PARTY INFORMATION Complete if patient is not responsible party or if patient is a minor.

RESPONSIBLE PARTY_____________________________________________________ SSN __________________________ (LAST) (FIRST) (MI)

ADDRESS _____________________________________________________________________________________________ (STREET) (APT.) (CITY) (STATE) (ZIP)

EMPLOYER ______________________________EMP STATUS: FT PT STUDENT( FT or PT ) RETIRED NOT EMPLOYED

INSURANCE INFORMATION Please complete below, AND give office copies of your cards.

PRIMARY INSURANCE ______________________________________ ID # _____________________________________

GROUP # _________________________________ PROVIDER ON CARD _______________________________________

INS. ADDRESS _________________________________________________________________________________________ (STREET) (SUITE) (CITY) (STATE) (ZIP)

POLICY HOLDER ________________________ DOB_______________ RELATIONSHIP TO PATIENT _________________

EMPLOYER ___________________________ EMP STATUS: FT PT STUDENT( FT or PT ) RETIRED NOT EMPLOYED

SECONDARY INSURANCE_____________________________________ ID # ____________________________________

GROUP # ______________________________ PROVIDER ON CARD _______________________________________

INS. ADDRESS _________________________________________________________________________________________ (STREET) (SUITE) (CITY) (STATE) (ZIP)

POLICY HOLDER ________________________ DOB_______________ RELATIONSHIP TO PATIENT _________________

EMPLOYER ___________________________ EMP STATUS: FT PT STUDENT( FT or PT ) RETIRED NOT EMPLOYED

EMERGENCY CONTACT

PERSON TO NOTIFY IN CASE OF EMERGENCY #1 ____________________________________

RELATIONSHIP _____________ PRIMARY PHONE #: (_____)____________, HOME / MOBILE / WORK

SECONDARY PHONE #: (_____)____________, HOME / MOBILE / WORK

Page 2 of 2

PERSON TO NOTIFY IN CASE OF EMERGENCY #2_________________________________________________

RELATIONSHIP _____________ PRIMARY PHONE #: (_____)____________, HOME / MOBILE / WORK SECONDARY PHONE #: (_____)____________, HOME / MOBILE / WORK

FOR OUR MINOR PATIENTS

CHILD PRIMARILY LIVES WITH: (please specify)_______________________________________________________

PARENT #1 INFORMATION

PARENT NAME __________________________________________________ RELATIONSHIP TO PATIENT _______________ (LAST) (FIRST) (MI)

BIRTHDATE _______ / _______ / _________ SSN __________________________

ADDRESS _____________________________________________________________________________________________ (STREET) (SUITE) (CITY) (STATE) (ZIP)


CELL PHONE (_____)_________________ OTHER (_____)___________________

PARENT #2 INFORMATION

PARENT NAME __________________________________________________ RELATIONSHIP TO PATIENT _______________ (LAST) (FIRST) (MI)

BIRTHDATE _______ / _______ / _________ SSN __________________________

ADDRESS _____________________________________________________________________________________________ (STREET) (SUITE) (CITY) (STATE) (ZIP)


CELL PHONE (_____)_________________ OTHER (_____)___________________

SIBLING NAMES (if any)

Name________________________________________________________________ Date of Birth________________




NO SHOW POLICY

As a patient in our Practice, it will be your responsibility to keep scheduled appointments. Our office requires notification of cancellation at least 24 hours prior to the appointment or earlier if possible. Please contact our office to cancel and reschedule an appointment.

The Practice will consider a "failed appointment" anytime a patient has not given the advance notice above. A No Show charge will be applied to your account if advance notice is not given. The charge will range from $25.00/$100.00 depending on the type of appointment missed.

SIGNATURE

I have read and agreed to the above for University HealthCare Alliance. I have reviewed and confirm that the information provided is correct. _______________________________________________________ __________________________ PATIENT/GUARDIAN/PATIENT REPRESENTATIVE SIGNATURE RELATIONSHIP TO PATIENT PRINT NAME (if other than patient) ____________________________________________ DATE _____________________

Name: ________________________________________ Date: __________________ Referring MD: ________________________________ DOB: ____________ Age: ______ PCP: ________________________Other MDs you see: ____________________________ What is the primary reason you have come to Cardiovascular Consultants? Are you having or have you ever had? (Check all for which the answer is yes)

� Increasing breathlessness with your usual activities � Shortness of breath at rest, lying down � Recent cough � Heart attack � Spells of rapid heartbeat � Pain, pressure / discomfort in the chest � Palpitations � Any neck, jaw, left arm discomfort � Passed (ing) out – fainting � Unexplained weight gain of more than 5 lbs. � Dizzy spells in the last weeks or months � Pain or cramps in leg(s) with walking � Worsening fatigue � A stroke or temporary stroke � Swelling of the ankles � Heart murmur � Abnormal EKG � Rheumatic fever � Have you been hospitalized for your heart or what they thought was your heart? � Any other cardiac diagnosis? � Any tests or surgeries done for your heart? What tests?_____________________________ When and where were they done? _____________________________________________ Is there any family history of?

� Heart attack � Sudden death � Bypass surgery � Hypertension � Angina � Diabetes � Clogged Arteries Where were you born? ______________________________________________________ City where you live: ________________________________________________________ What do/did you do for work? _________________________________________________

List other medical problems you have had. These would include problems for which you have taken medications or been hospitalized. Please include the dates these problems occurred. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________ List all surgeries you have had and when and where they occurred:

Surgery When Hospital Surgery When Hospital _________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Board Certified in Cardiovascular Diseases

Alameda County David J. Anderson, M.D. John H. Chiu, M.D. Robert C. Feldman, M.D. Eric L. Johnson, M.D. Steven Kang, M.D. Michael A. Lee, M.D. Paul L. Ludmer, M.D. Alden J. McDonald III, M.D. Jeffrey A. West, M.D. Gary R. Woodworth, M.D. Contra Costa County Kristine W. Batten, M.D. Andrew J. Benn, M.D. Ryan A. Brown, M.D. Matthew S. DeVane, D.O. Anurag Gupta, M.D. Faizul Haque, M.D. John R. Krouse, M.D. Mark D. Nathan, M.D. Pramodh S. Sidhu, M.D. John D. Vu, M.D. Neal W. White, M.D. Christopher W. Wulff, M.D. Electrophysiology Robert C. Feldman, M.D. Anurag Gupta, M.D. Steven Kang, M.D. Michael A. Lee, M.D. Paul L. Ludmer, M.D. Vascular John H. Chiu, M.D. Eric L. Johnson, M.D. Neal W. White, M.D. Christopher W. Wulff, M.D.

2400 Balfour Road Suite 215 Brentwood, CA 94513-4950 925.516.3230 FAX 925.516.3235 20126 Stanton Avenue Suite 100 Castro Valley, CA 94546-5270 510.537.3556 FAX 510.537.3610 365 Hawthorne Avenue Suite 201 Oakland, CA 94609-3114 510.452.1345 FAX 510.452.1102 5201 Norris Canyon Road Suite 220 San Ramon, CA 94583-5405 925.277.1900 FAX 925.277.1568 106 La Casa Via Suite 140 Walnut Creek, CA 94598-3084 925.274.2860 FAX 925.932.4527

www.ccmgonline.com

C: My Documents/ Master Forms/ Patient History Form 10.24.11

Risks Tobacco use: � Current � Former � Never � Unknown Type of Tobacco:________________________ Year Quit:_________Packs/Day:_____________ Ever tried to quit � No � Yes Year quit_______________________________ Longest tobacco free _____________________ Relapse reason __________________________ Passive smoke exposure � No � Yes

Family History of Premature Coronary Artery disease: (Male under 45 or Female under 55) � Yes � No � Adopted (No family history known) Diabetes: � Yes � No � Unknown

Cholesterol/Dyslipedimia: � Yes � No � Unknown Hypertension: � Yes � No � Unknown

Peripheral Vascular Disease: � Yes � No � Unknown

Social History Marital Status: � Divorced � Legally separated � Life partner � Married � Single � Widowed

Children: � Yes � No ____son(s) _____daughter(s) ______total

Life Style - Type of diet � Regular � Low fat, low cholesterol � Low salt � No added salt � Renal � Weight loss � Low carb � Diabetic � Vegetarian

Exercise: � Sedentary � Occasional � Regular � Active lifestyle � Physically unable to exercise Caffeine: � Yes � No

Alcohol Use: � Yes � No � Former Year Quit:_____ � Rarely � Frequently � Occasional � Social � Daily use

Illicit Drug Use � Yes � No � Former Personal: Primary Language ______________________ Secondary Language ___________________

Race: � American/Indian or Alaska Native � Black � Asian or Pacific Islander �Caucasian � Hispanic � Refuse � Unknown/Other

Ethnicity: � Hispanic or Latino � Not Hispanic or Latino � Refused

Advanced Directives: � None � DNR �HC Proxy � Living Will

� Disabled � Retired

Are you allergic to any medications? Yes � No � List those medications _________________________________________________________________________________________ Are you allergic to X-ray dye? Yes � No � Other Allergies? ___________________ Please bring in the bottles of all the medications you are currently taking

Page 1 of 8 Notice of Privacy Practices – September 23, 2013 supersedes all prior versions

IANC E

NOTICE OF PRIVACY PRACTICES Effective Date: September 23, 2013

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY.

OUR PLEDGE TO PROTECT YOUR PRIVACY

University HealthCare Alliance (the "Clinic" for purposes of this Notice) knows that health information about you is personal, and we are committed to protecting the privacy of the information we create or receive about you. Health information that identifies you (“protected health information” or “health information”) includes your medical record and other information relating to your care, or payment for care. We are required by law to:

♦ make sure that your health information is kept private; ♦ give you this Notice of our legal duties and privacy practices with respect to health information

about you; and ♦ follow the terms of the Notice that is currently in effect.

WHO WILL FOLLOW THIS NOTICE

The following parties share the Clinic's commitment to protect your privacy and will comply with this Notice:

♦ Any health care professional authorized to update or create health information about you; ♦ All departments and units of the Clinic; ♦ All employees, volunteers, trainees, students, contractors and practitioners of the Clinic; and ♦ All affiliated entities, sites and locations.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

The following sections describe different ways that we use and disclose your health information. To respect your privacy, we will try to limit the amount of information that we use or disclose to the "minimum necessary" to accomplish the purpose of the use or disclosure. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the following categories, regardless of the method in which the use or disclosure is made. Uses or disclosures of information may occur on paper, through the electronic health record or systems or other electronics means such as through health information exchanges. "You" in this Notice means a Clinic patient or, if applicable, the patient's personal representative. A personal representative is any person authorized to act on behalf of the patient with respect to his/her health care. For example, a personal representative may include the parent or guardian of a minor (unless the minor has the authority under California law to act on his/her own behalf), the guardian or conservator of an adult patient, or the person authorized to act on behalf of a deceased patient.


FOR TREATMENT: We may use health information to provide you with medical treatment or services. We may use and share health information about you to doctors, residents, nurses, technicians, medical students, or other Clinic personnel involved in your care. For example, a doctor treating you for a broken leg needs to know if you have diabetes because diabetes can slow the healing process. Different departments of the Clinic, such as schedulers, pharmacy, lab and x-ray, may share your health information to coordinate the services you need. We may disclose your health information to providers not affiliated with the Clinic to facilitate the care they provide you. For example, we may disclose your health information to specialty physicians for care coordination purposes. Additionally, we may provide access to your health information to affiliated entities and locations, such as an affiliated provider group for care coordination purposes. Electronic exchange of health information helps ensure better care and coordination of care. The Clinic may participate in health information exchange(s) that allow outside providers who need information to treat you access your health information through a secure health information exchange. FOR PAYM ENT: We may use and disclose your health information to bill and receive payment for health care services that we, or others, provide for you. This includes uses and disclosures to submit health information to receive payment from your health insurer, HMO, or other party that pays for some or all of your health care (payor) or to verify that your payor will pay for your health care. We may also tell your payor about a treatment you are going to receive to obtain prior coverage authorization or to determine whether your plan will cover the treatment. For certain services, your permission is needed to release health information and your permission will be asked to do so. FOR H EALTH CARE OPERATIONS: We may use and disclose h e a l t h information for health care operat ions . This includes functions necessary to run the Clinic or assure that all patients receive quality care, and includes many support functions such as appointment and procedure scheduling. We may also share your information with affiliated health care providers so that they may jointly perform c e r t a i n business operations along with the Clinic. For example, we may use medical information to review our treatment and services and evaluate the performance of our staff in caring for you. We may combine medical information about many of our patients to decide what additional services the Clinic should offer, what services are not needed, and whether certain new treatments are effective. We may share information with doctors, residents, nurses, technicians, medical students, clerks and other personnel for quality assurance and educational purposes. We may also compare the h e a l th information we have with information from other hospitals or clinics to see where we can improve the care and services we offer.


BUSINESS ASSOCIATES: The Clinic contracts with outside entities that perform business services for us, such as billing companies, management consultants, quality assurance reviewers, accountants or attorneys. In certain circumstances, we may need to share your health information with a business associate so it can perform a service on our behalf. We will have a written contract in place with the business associate requiring protection of the privacy and security of your health information. APPOINTMENT REMINDERS AND OTHER COMMUNICATIONS: We may use and disclose information to contact you as a reminder that you have an appointment for care at the Clinic. We will communicate with you using the information (such as telephone number and email address) that you provide. Unless you notify us to the contrary, we may use the contact information you provide to communicate general information about your care such as appointment location, department, date and time. TREATMENT OPTIONS AND ALTERNATIVES: We may use and disclose h e a l t h information to tell you about, or recommend, possible treatment options or alternatives that may be of interest to you. HEALTH-RELATED BENEFITS AND SERVICES: We may use and disclose h e a l t h information to tell you about health-related benefits or services that may be of interest to you. INDIVIDUA LS INVOLVED IN YOUR CARE: We may release health information about you to a family member or friend who is involved in your care. We may also give information to someone who helps pay for your care. Unless there is a specific written request from you to the contrary, we may also notify a family member, personal representative or another person responsible for your care about your location and general condition. This does not apply to patients receiving treatment for certain conditions such as substance/alcohol abuse. In addition, we may disclose medical information about you to an organization assisting in a disaster relief effort (such as the Red Cross) so that your family can be notified about your condition, status and location. FUNDRAISING ACTIVITIES Consistent with applicable state and federal laws, we may provide limited information such as your contact information, provider name and dates of care to Lucile Packard Foundation for Children’s Health or Stanford University Office of Medical Development to conduct fundraising activities for the advancement of care and research on behalf of the Clinic. RESEARCH: The Clinic is occasionally involved in studies that may involve your current care or that involve reviews of your medical history. For example, a study may involve an investigational procedure to treat a condition or compare the health and recovery of patients who have received one medication with those who have received another for the same condition. We generally ask for your written authorization before using your medical information or sharing it with others in order to conduct research. Under limited circumstances we may use and disclose your medical information without your authorization. In most of these latter situations, we must obtain approval through an


independent review process to ensure that research conducted without your authorization poses minimal risk to your privacy. Researchers may also contact you to see if you are interests in, or eligible, to participate in a study. TO PREVENT A SERIOUS THREAT TO HEALTH OR SAFETY: We may use and disclose certain information about you when necessary to prevent a serious threat to your health and safety or the health and safety of others. However, any such disclosure will only be to someone able to help prevent the threat, such as law enforcement, or to a potential victim. For example, we may need to disclose information to police when a patient reveals that he/she has participated in a violent crime.

SPECIAL SITUATIONS THAT DO NOT REQUIRE YOUR AUTHORIZATION WORKERS' COMPENSATION: We may release h e a l th information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness. PUBLIC HEALTH ACTIVITIES: We may disclose health information about you for public health activities. These activities include, but are not limited to:

♦ Preventing or controlling disease, injury or disability; ♦ Reporting births and deaths; ♦ Reporting the abuse or neglect of children, elders and dependent adults; ♦ Reporting reactions to medications or problems with products; ♦ Notifying you of the recall of products you may be using; ♦ Notifying a person who may have been exposed to a disease or may be at risk for

contracting or spreading a disease or condition; ♦ Notifying the appropriate government authority if we believe you have been the

victim of abuse, neglect or domestic violence. We will only make this disclosure when required or authorized by law; and

♦ Notifying appropriate state registries, such as the Northern California Cancer Center or the California Emergency Medical Services Authority, when you seek treatment at the Clinic for certain diseases or conditions.

HEALTH OVERSIGHT ACTIVITIES: We may disclose health information to a health oversight agency, such as the California Department of Health Services or the Center for Medicare and Medicaid Services, for activities authorized by law. These oversight activities include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. LAWSUITS AND DISPUTES: If you are involved in a lawsuit or a dispute, we may disclose your health information in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, legally enforceable discovery request, or other lawful process by someone else involved in the dispute.


LAW ENFORCEMENT: We may release health information a t the r eques t o f law enforcement officials in the following limited circumstances:

♦ In response to a court order, subpoena, warrant, summons or similar process; ♦ To identify or locate a suspect, fugitive, material witness, or missing person; ♦ About the victim of a crime if, under certain limited circumstances, the victim is

unable to consent; ♦ About a death we believe may be the result of criminal conduct; ♦ About criminal conduct at the Clinic; and ♦ In an emergency to report a crime, the location of the crime or victims, or the

identity, description or location of the person who committed the crime. CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS: We may release medical information to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also release health information about patients of the Clinic to funeral directors as necessary to carry out their duties with respect to the deceased. ORGAN AND TISSUE DONATION: We may release health information to organizations that handle organ, eye, or tissue procurement or transplantation, as necessary to facilitate organ or tissue donation. The procurement or transplantation organization needs your authorization for any actual donations. MILITARY AND VETERANS: If you are a member of the armed forces, we may release health information about you as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority. NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES: Upon receipt of a request, we may release health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. We will only provide this information after the Privacy Officer has validated the request and reviewed and approved our response. INMATES: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release may be necessary for the institution to provide you with health care, to protect your health and safety or the health and safety of others, or for the safety and security of the correctional institution. OTHER USES OR DISCLOSURES REQUIRED BY LAW: We will also disclose health information about you when required to do so by federal, state or local laws that are not specifically mentioned in this Notice.


SITUATIONS THAT REQUIRE US TO OBTAIN YOUR AUTHORIZATION For uses and disclosures not described above, we must first obtain your authorization. For example, the following uses and disclosures will only be made with your authorization:

♦ uses and disclosures for marketing purposes; ♦ uses and disclosures that constitute the sale of Protected Health Information; ♦ most uses and disclosures of psychotherapy notes; and ♦ other uses and disclosures not described in this notice.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

You have the following rights regarding the health information we maintain about you: RIGHT TO INSPECT AND OBTAIN A COPY OF YOUR MEDICAL RECORD: You have the right to inspect and obtain a paper or electronic copy of health information that may be used to make decisions about your care. Usually this includes your medical and billing records, but may not include some mental health information. We reserve the right to charge a fee to cover the cost of providing your records to you. RIGHT TO REQUEST CORRECTION/ADDENDUM TO YOUR MEDICAL RECORD: Appropriate written request for correction/addendum must be filed with Clinic Health Information Management Services Department Correction: If you believe that health information the Clinic has on file about you is

incorrect or incomplete, you may ask us to correct the health information in your records. If your medical information is accurate and complete, or if the information was not created by the Clinic, we may deny your request; however, if we deny any part of your request, we will provide you with a written notice of our reasons for doing so.

Addendum: Even if the correction is denied, an adult Clinic patient who believes an item or statement in his/her medical record is incorrect or incomplete has the right to provide the Clinic with a written addendum to his/her record.

RIGHT TO AN ACCOUNTING OF DISCLOSURES: You have the right to request an "accounting of disclosures" which is a list describing how we have shared your health information with outside parties. This accounting is a list of the disclosures we made of your health information after April 14, 2003 for purposes other than treatment, payment and health care operations, and certain other purposes consistent with the law. You may request an accounting of disclosures up to six years before the date of your request. If you request an accounting more than once during a twelve month period, we will charge a reasonable fee. RIGHT TO REQUEST RESTRICTIONS: You have the right to request restrictions on certain uses or disclosures of your health information. For example, you may request that we not disclose information about a procedure you had. Requests for restrictions must be in writing and forms are available at registration areas. In most cases, we are not required to agree to your requested restriction. However, if we do agree, we will comply with your request unless the information is needed to provide you emergency treatment or comply with the law. If we cannot accommodate your request, we will notify you in writing explaining why we cannot do so.


We are legally required to accept certain requests not to disclose health information to your health plan for payment or health care operations purposes as long as you have paid out-of-pocket and in full in advance of the particular service If the service or item is part of a set of related services, and you wish to restrict disclosures for the set of services, you must pay in full for all related services. Please notify the scheduling person so that we can fully accommodate your request. We will comply with the request unless otherwise required by law. RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS: You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work, rather than at your home. We will not ask you the reason for your request, and we will use our best efforts to accommodate all reasonable requests. Requests must be in writing using forms available at the clinic registration area. RIGHT TO OPT-OUT OF FUNDRAISING COMMUNICATIONS: As part of fundraising activities, the Lucile Packard Foundation for Children's Health or the Stanford University Office of Medical Development may contact you to make you aware of giving opportunities for the Medical Center. You have the right to request to opt-out of receiving fundraising communications. Fundraising communications will include information about how you can opt-out from receiving future fundraising communications. RIGHT TO RECEIVE NOTIFICATION OF A BREACH OF YOUR HEALTH INFORMATION: The Clinic is committed to safeguarding your health information and proactively works to prevent health information breaches from occurring. If a breach of unsecured health information occurs, we will notify you in accordance with applicable state and federal laws. RIGHT TO A COPY OF THIS NOTICE UPON REQUEST: You have the right to a copy of this Notice. It is available in registration areas.

OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this Notice, or the laws that apply to us, will be made only with your written authorization. If you provide us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the activities covered by the authorization, except if we have already acted in reliance on your permission. We are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provided to you.


REQUEST FOR COPY OF HEALTH INFORMATION To obtain information about how to request a copy of your medical or billing records, receive an accounting of disclosures of, or correct or add an addendum to your medical information, please contact and/or file completed form with:

1. Your Clinic Health Information Management Department, or 2. Director of Health Information Management

University HealthCare Alliance 855 Oak Grove Avenue, Suite 207 Menlo Park, CA 94025 Telephone #: 650-736-6930 FAX #: 650-321-4897

COMMENTS OR COMPLAINTS

We welcome your comments about our Notice and our privacy practices. If you believe your privacy rights have been violated, you may file a complaint with:

University HealthCare Alliance Director of Compliance 855 Oak Grove, Suite 105 Menlo Park, CA 94025 Phone: 650-724-0326 Fax: (650) 323-1494

or with the Secretary of the Department of Health and Human Services (200 Independence Avenue, S.W., Washington, D.C. 2020 I). Please be assured that no one will retaliate or take action against you for filing a complaint.

CHANGES TO THIS NOTICE We reserve the right to change our privacy practices and update this Notice accordingly. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We post copies of the current Notice in the Clinic and on our Internet sites. If the Notice is changed, we will post the new Notice in our registration areas and provide it to you upon request. The Notice contains the effective date on the first page, in the top right-hand corner. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE PLEASE CONTACT UHA’S DIRECTOR OF COMPLIANCE AT (650) 724-0326

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To Our Patients, Insurance reimbursement for provided medical services is currently inadequate to cover the significant cost of operating a medical practice. As a consequence, for our practice to be able to continue providing high quality cardiology care, we must charge our patients directly for some non-clinical services provided by our practice. The services that we will provide for you but that require advanced payment are as follows:

1. Medical record copying - $20 (extensive record copying will be charged at a higher rate)

2. Completing insurance inquiry or disability forms - $20 (extensive forms will be

charged at a higher rate) 3. Completing Department of Motor Vehicle medical evaluation forms –$20

4. Handicap parking applications - $10

5. Copy of a study on CD - $20

6. Missed nuclear study - $468 (isotope) + $50 (no show)

7. No show or missed appointment - $50

Payment for the services listed above is expected prior to our provision of these services. In order to prevent a delay in the completion of your forms your payment must accompany the forms you mail or fax to us.

I have read the above and agree to the conditions stated here.

Signature: ____________________________________________ Date: ____________________________