Medical Treatment: The patient consents to the treatment, services, and procedures which may include but are not limited to: laboratory procedures, medical and surgical treatments or procedures, or anesthetics under the general or specific instructions of the responsible health care provider. As part of our mission to provide optimal health care for our patients, we allocate the use of the Arizona Prescription Monitoring program. This program is a tool used to promote public health and welfare by detecting diversion, abuse, and misuse of prescription medications classified as controlled substance(s) under the Arizona Uniform Controlled Substances Act.
Teaching Program: Family First Physician’s participates in training programs for physician assistants and health care personnel. Some patient services may be provided by persons in training under the supervision and instruction of the
physician or practice employees. These person’s in training may also observe care given to the patient by physician(s) and/or practice employees.
Contraband: Drugs, alcohol, weapons, and other articles specified as contraband by Family First Physicians are not allowed on office premises. Any illegal substance will be confiscated and turned over to the authorities.
Valuables: Neither Family First Physician’s nor the health care provider’s will be responsible for loss or damage to items brought by the patient to the facility, including but not limited to cell phones, tablets, laptops, glasses, contact lenses,
dentures, hearing aids, jewelry, money, or any other personal items.
Photography/Video Recording: I understand and agree that a photograph may be taken of me for identification purposes or for other treatment purposes. I will not take pictures or record videos of any Family First Physician staff member without their permission.
Release of Information: According to Arizona State Law, A.R.S. §12-2294 and §12-2294.01 require physicians to disclose medical records without the patient’s written authorization as required by law or when ordered by a court or tribunal of competent jurisdiction. This includes subpoenas. When required for diagnosis or treatment of the patient, a physician may disclose the medical records without written authorization from the patient to other health care providers. And the doctor may disclose them to other health care providers who have previously treated the patient without the patient’s written approval. Doctors may also release them to ambulance attendants, to a private agency that accredits health care providers, to the Arizona Medical Board, to health care providers for peer review, to a person or entity that provides billing and
administrative services, to an attorney for the purpose of obtaining legal advice, to the patient’s third-party payor, or to the Industrial Commission of Arizona. Included information may be regarding alcohol or drug abuse as well as HIV-related or other communicable diseases.
HIE Participation: I acknowledge that I received and read the Notice of Health Information Practices. I understand that my healthcare provider participates in Health Current, Arizona’s health information exchange (HIE). I understand that my health information may be securely shared through the HIE, unless I complete and return an Opt Out Form to my healthcare provider.
HIPAA: The HIPAA Privacy Rule establishes national standards to protect individuals’ medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of personal health information and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The Rule also gives patient's rights over their health information, including rights to examine and obtain a copy of their health records and to request corrections. You will be provided with a copy of the office's HIPPA regulations which is your copy to keep.
By signing below, I confirm that I have read and understood Family First Physician’s Medical Treatment Agreement.