Telemedicine services involve the use of secure interactive videoconferencingequipment and devices that enable health care providers to deliver health careservices to patients when located at different sites.
You have been given the Notice of Privacy Practices for Dr. Kasper's Concierge Medical Group. This Notice describes your legal right regarding your health information and will inform you of the legal duties and privacy policies. If you receive services by your physician or other health care provides at a different location, you may want to ask about the office or clinic's health information privacy policies and notices. they could be different.
This Notice of Privacy Practices is one document for your convenience. This practice is independently responsible for complying with this Notice. We are not responsible for each other's action and do not have equal control over the other's business.
Your legal name and signature below indicate that you have read and understand this Notice of Privacy Practices. Click HERE to download a copy of our Privacy Practices.
If you have a question regarding any of the information set forth in this Notice of Privacy Practices, please do not hesitate to contact Dr. Kasper's Concierge Medical Group office at (832) 948-6942.
A. I hereby request access to my records held by DOUGLAS KASPER MD, DR. KASPER'S CONCIERGE MEDICAL GROUP.
My signature indicates that I have read and acknowledge the above Consent to Treatment, Release of Information and Notice of Privacy Practices and agree to all the terms as indicated.
By Initialing here, you have NOT read the Consent to Treatment, Release of Information or Notice of Privacy Practices: initials here
*If signed by a Qualified Personal Representative, the following must be completed:
Dr. Kasper's Concierge Medical Group occasionally sends newsletters, updates and event information to the provided email address or phone number. I understand that I may opt out of receiving these communications at any time and I consent to the use of my email address and phone number for these purposes. Some tests results may be sent to you via ENCRYPTED EMAIL. A consent is required to have results sent by this method.
In an effort to improve the continuity of care, you may be referred to a primary care physician, if you do not already have one and/or a specialist. The referral information will be provided to you as a part of your discharge paperwork. Do you consent to Dr. Kasper's Concierge Medical Group providing the Referral Physician your contact information for the purpose of contacting you to setup a follow up visit?
If you select YES, Your name, phone number and reason for referral will be provided.
NOTICE CONCERNING COMPLAINTS
Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:
Texas Medical Board Attention: Investigations
333 Guadalupe, Tower 3, Suite 610
P.O. Box 2018, MC-263 Austin, Texas 78768-2018
Assistance in filing a complaint is available by calling the following telephone number:
For more information, please visit our website at
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