Family Medical History: please list if any of the below family members have been diagnosed with any medical problems.
Review of Symptoms: (check the symptoms that apply to you, please review list carefully)
To prepare for your visit:
If you have had any labs done in the last 12 months, please upload them below. Ideally these are labs done by a primary care doctor and/or "wellness visit labs" and include the following labs: basic metabolic panel, liver function tests, TSH, lipid panel, fasting glucose test or Hba1c, and uric acid test (only if you have a history of gout).
If you do not have labs available to upload at this time, please either have your Doctor fax your labs to us at 844-793-9467 or you can email them to email@example.com any time prior to your appointment.
If you do not have any of these labs done within the last 12 months, Dr Shah can order them for you.
As a courtesy to our patients, we will gladly file the forms necessary so that you receive the full benefits of your medical coverage. We ask that you read your insurance policy to be fully aware of any limitations of the benefits provided. If you are concerned about coverage for any of our services, please contact your insurance company prior to your visit. If your insurance company denies coverage, or we otherwise do not receive payment 60 days from filing your claim, the amount will then become due and payable by you. Remember that your coverage is a contract between you and your insurance company and/or your employer and your insurance company. Although we will make a good faith effort to assist you in obtaining your benefits,we cannot force your insurance company to pay for the services we have provided to you.
If your insurance changes it is the patient’s responsibility to verify that VITALITY WEIGHT LOSS AND WELLNESS INSTITUTE PLLC is contracted with the new insurance plan. If your insurance changes, most insurances require that you see Dr Shah to establish care under the new insurance before meeting with the dietitian/nutritionist. You will be responsible for ensuring we are aware of your new insurance and for establishing care with Dr Shah again prior to seeing the dietitians/nutritionists.
If you have an HMO plan or a plan that requires insurance approval/authorization prior to being seen by the Doctor, it is the patient's responsibility to ensure we have this on file prior to being seen. Failure to do this may result in denial of claims.
Copays, deductibles, and coinsurance are due at the time of service. NO EXCEPTIONS will be made.
We do NOT accept cash or checks. The only form of payment accepted is credit/debit cards.
Credit Card on File Policy: Vitality is committed to making our billing process as simple and easy as possible. We require that all patients provide a credit card on file with our office. We will store your card number in a secure, compliant location in your electronic medical record. For security reasons only the last four digits will be visible to our staff. Credit cards on file will be used to pay copays when you are seen in our office, including account balances, after your insurance processes your claim.
You will be notified by email of pending charges 5 days before the charges occur, and again when the credit card is charged. You will also receive an email receipt when the card is charged.
All balances must be paid in full before removing the credit card on file.
If your credit card fails, you will be charged a $50 fee.
Meal Replacement Policy: ALL PRODUCT SALES ARE FINAL SALE AND NON REFUNDABLE.
We gladly reserve appointment times for you and appreciate that you have chosen Vitality for your care. As a courtesy, we will remind you of your appointment by calling and/or text/emailing you prior to your scheduled date and time. However, in the event your mailbox is full, or your line is busy, our efforts to contact you may be unsuccessful. An appointment is a contract of time reserved for your treatment. We respect our patient’s valuable time, and we request the same courtesy from our patients. Please extend this courtesy should you need to cancel and/or reschedule your appointment. We reserve the right to charge $75 for regular appointments cancelled or broken without advance notice of 2 business days.
Assignment and Release:
I authorize payment to be made directly to Vitality by my insurance company, and I accept financial responsibility for all services not covered by my insurance. I authorize the release of any medical care information requested by my insurance company. My signature below acknowledges that I have read and understand this information.
I have read the information above and agree to all of the terms outlined.
Use and Disclosure: We may use or disclose your PHI for treatment, payment or health care operations. For your convenience, we have provided the following examples of such potential uses or disclosures.
Treatment: Your PHI may be used by or disclosed to any physicians or other health care providers involved with the medical services provided to you.
Payment: Your PHI may be used or disclosed in order to collect payment for the medical services provided to you.
Health Care Operations: Your PHI may be used or disclosed as part of our internal health care operations. Such health care operations may include among other things, quality of care audits of our staff and affiliates, conducting training programs, accreditation, certification, licensing or credentialing activities.
Authorizations: We will not use or disclose your medical information for any reason except those described in this Notice, unless you provide us with a written authorization to do so. We may request such an authorization to use or disclose your PHI for any purpose, but you are not required to give us such authorization as a condition of your treatment. Any written authorization from you, may be revoked by you in writing at any time, but such revocation will not affect any prior authorized uses or disclosures.
Patient Access: We will provide you with access to your PHI, as described below in the Individual Rights section of this Notice. With your permission, or in some emergencies, we may disclose your PHI to your family members, friends, or other people to aid in your treatment or the collection of payment. A disclosure of your PHI may also be made if we determine it is reasonably necessary or in your best interest for such purposes as allowing a person acting on your behalf to receive filled prescriptions, medical supplies, X-rays, etc.
Locating Responsible Parties: Your PHI may be disclosed in order to locate, identify or notify a family member, your personal representative, or other persons responsible for your care. If we determine in our reasonable professional judgment that you are capable of doing so, you will be given the opportunity to consent to or to prohibit or restrict the extent of recipients of such disclosure. If we determine that you are unable to provide such consent, we will limit the PHI disclosed to the minimum necessary.
Disasters: We may use or disclose your PHI to any public or private entity authorized by law or by its charter to assist in disaster relief efforts.
Required by Law: We may use or disclose your medical information when we are required to do so by law. For example, your PHI may be released when required by privacy laws, workers’ compensation or similar laws, public health laws, court or administrative orders, subpoenas, certain discovery requests, or other laws, regulations or legal processes. Under certain circumstances, we may make limited disclosures of PHI directly to law enforcement officials or correctional institutions regarding an inmate, lawful detainee, suspect, fugitive, material witness, missing person, or a victim or suspected victim of abuse, neglect, domestic violence or other crimes. We may disclose your PHI to the extent reasonably necessary to avert a serious threat to your health or safety or the health or safety of others. We may disclose your PHI when necessary to assist law enforcement officials to capture a third party who has admitted to a crime against you or who has escaped from lawful custody.
Deceased Persons: After your death, we may disclose your PHI to a coroner, medical examiner, funeral director, or organ procurement organization in limited circumstances.
Research: Your PHI may also be used or disclosed for research purposes only in those limited circumstances not requiring your written authorization, such as those that have been approved by an institutional review board that has established procedures for ensuring the privacy of PHI.
Military and National Security: We may disclose to military authorities the medical information of Armed Forces personnel under certain circumstances. When required by law, we may disclose your PHI for intelligence, counterintelligence, and other national security activities.
YOUR INDIVIDUAL RIGHTS
Access and Copies: In most cases, you have the right to review or to purchase copies of your PHI by requesting access or copies in writing to our Practice Manager. Please contact our Practice Manager regarding our copying fees.
Disclosure Accounting: You have the right to receive an accounting of the instances, if any, in which your PHI was disclosed for purposes other than those described in the following sections above: Use and Disclosures, Patient access, and Locating Responsible Parties. For each 12-months, you have the right to receive one free copy of an accounting of certain details surrounding such disclosures that occurred after your initial visit.
If you request a disclosures accounting more than once in a 12-month period, we will charge you a reasonable, cost based fee for each additional request. Please contact our Practice Manager regarding these fees.
Additional Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your PHI, but we are not required to honor such a request. We will be bound by such restrictions only if we agree to do so in writing signed by our Practice Manager.
Alternate Communications: You have the right to request that we communicate with you about your PHI by alternative means or in alternative locations. We will accommodate any reasonable request if it specifies in writing the alternative means or location, and provides a satisfactory explanation of how future payments will be handled.
Amendments to PHI: You have the right to request that we amend your PHI. Any such request must be in writing and contain a detailed explanation for the requested amendment. Under certain circumstances, we may deny your request, but will provide you a written explanation of the denial. You have the right to send us a statement of disagreement to which we may prepare a rebuttal, a copy of which will be provided to you at no cost. Please contact our Practice Manager with further questions about amending your medical record.
Complaints: If you believe we have violated your privacy rights, you may complain to us or to the Secretary of the U.S. Department of Health and Human Services. You may file a complaint with us by notifying our Practice Manager.
We support your right to protect the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
GROUP VISIT HIPAA NOTICE
You may choose to participate in a group visit. During a group visit, it is possible that some of my individually identifiable health information will be disclosed. I have read and I understand the following statements about my rights: I realize that I have the option to be seen individually; I understand that I am not required to sign this form to receive health care treatment; I understand that discussions may occur regarding individually identifiable health information during a group visit; it is possible that the information that is used or disclosed in a group visit may be re-disclosed by other participants in the group visit; I have been notified of this potential disclosure, and I voluntarily wish to participate in this group.
Social Media Disclaimer
Vitality Weight Loss supports and encourages the use of social media. It's a great way to learn both from our staff and from your colleagues and peers. Use of our social media websites such as Facebook, Instagram, and LinkedIn are completely voluntary and optional.
Keep in mind your comments and postings are not private and can be seen by other people. We recommend you do not post anything you would not want everyone on the Internet to read.
Below are the terms and conditions of using Vitality Weight Loss's social media websites. The terms and conditions are subject to change without notice.
By posting information to one of the social media sites you agree that you are responsible for the information you posted. You agree to use the social media sites in a responsible manner and will not use the sites to: post offensive comments, use offensive language, defame or personally attack another person, for illegal activities, to harass another person, to promote organizations or events not related to the content of the site, to release private information about a patient.
If you choose to participate on our social media sites and voluntarily post pictures or information about yourself, you grant Vitality Weight Loss the irrevocable right to reproduce, distribute, publish, and display such content and the right to create derivative works from your content, edit or modify such content and use such content for the clinics purpose.
Vitality Weight Loss reserves the right to monitor, prohibit, restrict, block, suspend, terminate, delete, or discontinue your access to any Vitality Weight Loss site, at any time, without notice, for any reason and at its sole discretion.
I authorize the provider to release information regarding my diagnosis and treatment to my Health Insurance Company, Attorney, and Insurance adjustor for purposes of processing payment claims for services rendered to me.
I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.This information may be disclosed to and used by Vitality Weight Loss and Wellness Institute, PLLC for the purpose of my care.
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure, and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact Vitality Weight Loss and Wellness Institute.
I hereby authorize any health care professional, medical facility, mental health facility, laboratory, paramedical facility, medical examiner, medical records service, prescription history clearing house, consumer reporting agency, employer, and family member to release all health information about me.
The following person/organization is hereby authorized to receive my entire medical record, treatment record and diagnostic record:
Vitality Weight Loss
2633 Dallas Parkway
Plano, Texas 75093
280 Adriatic Pkwy
McKinney, Texas 75070
Phone: 972-737-3296Fax: 844-793-9467Email:firstname.lastname@example.org
By my signature below, I acknowledge that any prior agreement I have made to restrict or limit the disclosure of information about my health does not apply to this authorization. The following health information that relates to service beginning now and future may be released:
Entire Medical Record including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent by other health care providers.I further understand that my medical record may include one or more of the following:
Treatment of communicable diseases, including sexually transmitted diseases, venereal diseases, tuberculosis, or hepatitis, HIV-Related Treatment, Mental Health Information or Psychological Conditions, Alcohol or Substance Abuse Treatment, Genetic Testing
I understand and agree that health information about me, which is used or disclosed pursuant to this authorization, may be subject to re-disclosure by the recipient and may no longer be protected by law.
A copy, electronic copy, image, or facsimile of this authorization is as valid as the original. I have the right to revoke this authorization in writing at any time. I acknowledge that such a revocation is not effective to the extent the above person/organization has relied on the use or disclosure of my health information.
I have read (or have had read to me) this authorization, and I agree to its terms as indicated by my signature below. I am entitled to a copy of this authorization.
Vitality Telemedicine Consent
Telemedicine involves the real-time evaluation, diagnosis, consultation on, and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video, or other electronic media. As such, telemedicine allows the provider to see andcommunicate with the patient in real-time.
II. I voluntarily request the physician(s) and such associates, clinical staff, technical assistants and otherhealth care providers as they may deem necessary (“Vitality Telemedicine Providers”) to participate in my medical care through the use of telemedicine.
III. I understand that Vitality Telemedicine Providers may practice in a different location than where I present for medical care, may not have the opportunity to perform an in-person physical examination, and rely on information provided by me. I acknowledge that Vitality Telemedicine Provider’s advice, recommendations, and/or decision may be based on factors not within their control, such as incomplete or inaccurate data provided by me or distortions of diagnostic images or specimens that may result from electronic transmissions.
I acknowledge that it is my responsibility to provide information about mymedical history, condition and care that is complete and accurate to the best of my ability.
I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as a result or cure.
IV. If Vitality Telemedicine Providers determine that the telemedicine services do not adequately address my medical needs, they may require an in-person medical evaluation. In the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means ofcommunication may be implemented or an in-person medical evaluation may be necessary.
If I experience an urgent matter, such as a bad reaction to any treatment after a telemedicine session, I should alert my treating physician and, in the case of emergencies dial 911, or go to the nearest hospital emergency department