• BERNARD L. MARKOWITZ, M.D., F.A.C.S.
    A MEDICAL CORPORATION
    9675 BRIGHTON WAY, SUITE 350 BEVERLY HILLS, CA 90210
    Tel: (310) 205-5557 Fax: (310) 205-5595

  • PATIENT INFORMATION

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Birthdate:*
     - -
  • Sex:*
  • Relationship Status:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • I irreversibly assign to Dr. Bernard Markowitz all my right, without limitation, pertaining to my insurance carrier relating to services that Dr. Markowitz provided to me. I understand and agree that Dr. Markowitz may pursue those rights through demand letters, settlement, and litigation until finished, and that Dr. Markowitz will keep all money paid by my insurance carrier. I understand and agree that Dr. Markowitz may irreversibly reassign such matters and payments to someone else in order to pursue these matters. I direct my insurance carrier to pay all sums directly to Dr. Markowitz or to the party receiving the reassignment.

    I, {name} HAVE CAREFULLY READ AND UNDERSTAND THIS ASSIGNMENT, AND ACCEPT, APPROVE, AND AGREE TO THIS ASSIGNMENT.

  • Date:
     - -

  • MEDICAL HISTORY

  • High Blood Pressure:*
  • Skin Disease:*
  • Bleeding Disorder:*
  • Thyroid Disease:*
  • Anemia:*
  • Lung Disease:*
  • Liver Disease:*
  • Tuberculosis:*
  • Heart Disease:*
  • Shortness of Breath:*
  • Psychiatric Illness:*
  • Hepatitis:*
  • HIV:*
  • Diabetes:*
  • Latex:*
  • Other:*

  • FAMILY HISTORY

    Please give the age of living or if deceased, cause of death and age of deceased.

  • MEDICATIONS

  • Do you take any aspirin or any aspirin containing compound?*

  • Do you have any ALLERGIES and/or SENSITIVITIES: (please indicate which, if any are present):

  • Penicillin:*
  • Aspirin:*
  • Sulfa:*
  • Xylocaine:*
  • Any Other Antibiotics:*
  • Adhesive Tape:*
  • Codeine:*
  • Tetanus Toxoid:*

  • SOCIAL HISTORY

  • Cigarette Smoking:*
  • Alcohol Use:*
  • Caffeine:*
  • Do you take Vitamin E?*

  • SURGICAL HISTORY

    Please list all previous surgeries/operations, including cosmetic:
  • Date:
     - -
  • Date:
     - -
  • Date:
     - -
  • Date:
     - -
  • Do you wear corrective eye glasses or contacts?*
  • Date of last ophthalmology (eye) check up?*
     - -
  • Have you recently been under the care of a physician for any reason?*
  • Date of last check up:
     - -
  • Format: (000) 000-0000.

  • Notice of Privacy Practices

    Bernard L. Markowitz, M.D.

    Harley R. Liker, M.D.

     

    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.

     

    The Health Insurance Portability & Accountability Act of 1996 (HIPPA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential.  This Act gives you, the patient, significant new rights to understand and control how your health information is used.

    “HIPPA” provides penalties for covered entities that misuse personal health information.

     

    As required by “HIPPA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

     

    We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.

     

    • Treatment means providing, coordinating, or managing health care or related services by one or more health care providers.  An example of this would include a physical examination.

     

    • Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review.  An example of this would be sending a bill for your visit to your insurance company for payment.

     

    • Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, functions, cost-management analysis, and customer service.  An example would be an internal quality assessment review.

     

    We may also create and distribute de-identified health information by removing all references to individually identifiable information.

     

    We may contact you to provide appointment reminders or information about treatment alternatives or other health related business and services that may be of interest to you.

     

    Any other uses or disclosures will be made only with your written authorization.  You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

     

    You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

     

    • The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close, personal friends, or any other person identified by you.  We are not required, however, to agree to a requested restriction.

     

    • The right to reasonable requests to receive confidential communications of protected health information from us by an alternative means or at alternative locations.

     

    • The right to inspect and copy your protected health information.

     

    • The right to amend your  protected health information.

     

    • The right to receive an accounting or disclosures of protected health information.

     

    • The right to obtain a paper copy of this notice from us upon request.

     

    We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

     

    This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect.  We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain.  We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

     

    You have recourse if you feel that your privacy protections have been violated.  You have the right to file a written complaint with our office, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office.

    We will not retaliate against you for filing a complaint.

     

    Also, effective June 27, 2010 physicians in California must inform their patients that they are licensed by the Medical Board of California, and include the Board’s contact information.  Please note:

     

     NOTICE TO CONSUMERS

    Medical doctors are licensed and regulated by the

    Medical Board of California

    (800) 633-2322

    www.mbc.ca.gov

     

    Please contact us for more information:                                                            For more information about HIPPA, or to file a complaint:

     

    Bernard L. Markowitz, M.D.                                                                              The U.S. Department of Health and Human Services

    Harley R. Liker, M.D.                                                                                        Office of Civil Rights

    9675 Brighton Way, Suite 350                                                                           200 Independence Avenue, S.W.

    Beverly Hills, CA  90210                                                                                   Washington, D.C.  20201

    (310) 205-5557                                                                                               (202)619-0257 or 1-877-696-6775

  • Bernard L. Markowitz, M.D.

    A Medical Corporation

    9675 Brighton Way, Suite 350

    Beverly Hills, CA  90210

     

     

     

     NOTICE OF PRIVACY PRACTICES &

    NOTICE TO CONSULMERS REGULATION

    ACKNOWLEDGEMENT OF RECEIPT

     

     

    This document serves as notification from Bernard L. Markowitz, M.D., a Medical Corporation of our Privacy Practices and the Notice to Consumers regulation.  Please review it carefully.  It outlines your right by law to understand and control how your health care information is used.  Your signature acknowledges that you have received this information.

     

    I acknowledge that I have received the Notice of Privacy Practices and the Notice to Consumers regulation.

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