Dear New Patient,

We are pleased to have you at La Verne Medical Group and hope to provide you with a great care experience! In order to do so, we need to know some information about you. Please fill out this Welcome Packet to the best of your ability.Thank you!

RELEASE OF INFORMATION/ ASSIGNMENT OF BENEFITS FOR LA VERNE MEDICAL GROUP:

I hear by authorize the above named provider(s) to disclose when requested by the above named insurance carrier or its representatives any and all information with respect to any illness(es) or injury(s), medical history or treatment and copies of all medical records. A photocopy of this authorization shall be considered as effective and valid as the original. I authorize payment to the above named provider(s) the amount due in my pending claim for basic medical, major medical, and/or surgical treatment or services by reason of such treatment or services. I have read the information above and hereby give my permission to administer treatment, and to perform such procedures as may be deemed necessary in diagnosis and/or treatment of my condition.

Do any of your blood relatives have the below conditions? If YES, please list the relationship, whether the relationship is maternal/paternal, and the age of diagnosis. 

RESPIRATORY:

GI TRACT:

COLONOSCOPY

URINARY SYSTEM:

PERIPHERAL VASCULAR SYSTEM:

CENTRAL NERVOUS SYSTEM:

Do you frequently have severe headaches? IF YES, PLEASE MARK BELOW.

HEMATOLOGY:

MUSCULOSKELETAL SYSTEM:

SKIN:

TB EXPOSURE RISK ASSESSMENT:

Article I: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California State Law, and not by a lawsuit or resort to court process expect as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in court of law before a jury, and instead are accepting the use of arbitration.

Article II: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.

Article III: 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 arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such 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 and witness fees, or other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.

The parties consent to the intervention and joinder in this arbitration of any person or entity which 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 California law applicable to health care providers shall apply to dispute within this arbitration agreement, including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure Section 1283.05, however, depositions may be taken without prior approval of the neutral arbitrator.

Article IV: General Provisions: 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 data notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article V: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

Article VI: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provision 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. By my signature below, I acknowledge that I have received a copy. Notice: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUES MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRAIL. SEE ARTICLE I OF THIS CONTRACT.

GOVERNMENT COMPLIANCE

In compliance with the recently enacted Patient Protection and Affordable Care Act and the Stark Law, La Verne Medical Urgent Care must inform you that there are other options pertaining to laboratory, diagnostic, and radio-graphic services. Specifically it should be noted that you have presented to La Verne Medical Urgent Care voluntarily for your medical needs and that as part of the evaluation of your condition and any required treatment, the physician on duty may determine that particular laboratory, diagnostic, and radio-graphic tests may be needed. La Verne Medical Urgent Care offers many of these services on-site as a convenience to our patients. If any patient would like to have their laboratory or radio- graphic services provided at another location we can provide you with a list of nearby locations.

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.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry on treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It all describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information that may identify you and that relates to you past, present, or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information:

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services for you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your healthcare with a third party. For example, your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your PHI will be used, as needed to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected information be disclosed to the health plan to obtain approval for the hospital admission.
Health Care Operations: We may use or disclose, as-needed, your PHI in order to support the business activities of your physician’s practice. These activities include but are not limited to, quality assessment activities, employee review activities, or training of medical students.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required by Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or NeglectL Food and Drug Administration: Legal Proceedings: Military Activity and National Security: Workers’ Compensation: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements section 164.500.

Other Permitted & Require Uses & Disclosures will be made with your consent, authorization or opportunity to object unless required by the law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS:

Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Your request must state the specific restriction requested and to whom you want the restriction to apply.
You have the right to request a restriction of your protected health information.
Your physician in not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclose your PHI, your PHI will not be restricted. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You may have the right to have your physician amend your PHI. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint.
This notice was publishes and becomes effective on/or before September 15, 2017.
We are required by law to maintain the privacy of and provide individuals with this notice of our legal duties and privacy practices with respect to PHI. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at 909-596-4879.

Signature below is only acknowledgment that you have received this Notice of our Privacy Practices:

I authorize the release of my medical records, information, treatment and advice, and specific health information to:

TREATING PHYSICIANS on staff at La Verne Medical Urgent Care and their staff, agents of another healthcare facility if direct transfer to another facility is required, and to my primary care physician or any referred consultants for follow up care.
AN EMPLOYER who requests services. This may include your personal medical history, physical, laboratory and diagnostic tests, and drug screenings (including the presence of drugs, alcohol or marijuana).
INSURANCE COMPANY or other third party payer and their agents as well as any review organization or government agency for the purpose of determining eligibility and available benefits, obtaining payment for services provided, and insuring government compliance.
EDUCATIONAL OR SCIENTIFIC INSTITUTIONS authorized health care professionals in training, internal quality improvement, risk management and legal counsel when it is judged that my ongoing medical care, medical research, quality improvement, healthcare education or science will benefit; for any purpose authorized by law.

I understand that if I refuse to authorize access to my records for coordination of care, my treatment could be adversely effected and that I could be held liable for the full cost of services provided by La Verne Medical Urgent Care. I understand this information may contain my personal medical history, physical, and treatments (if necessary), radio-graphic and laboratory results. I understand that I have the right to revoke this authorization.