New Patient Enrollment

Thank you for choosing Veterans Wellness Center of Alabama (VWC) as a Healthcare provider. We ask that you complete this 'New Patient' enrollment form prior to your first appointment.

All new patients are required to provide their insurance card(s), driver license, and/or photo IDs. All cards must be presented at your first visit. 

If you are being seen for services outside of Primary Care, it is your responsibility to confirm if your insurance requires you to have a referral; please obtain the referral from your Primary Care Provider (PCP).

If you wish to have David Graham, RN, MSN, NP-C as your Primary Care Provider you must notify your insurance company. Only the patient can change their PCP.

 

We look forward to serving you. 

 

David Graham, RN, MSN, NP-C

I hereby authorize Veterans Wellness Center of Alabama to release any information  necessary to process any insurance claim acquired during my examination and/or treatment; to allow a photocopy of my signature to be used to process any insurance claim. I claim, direct, and authorize my carrier to issue payment check(s) directly to VWC of Alabama for insurance benefits to which I am entitled. I understand that failure to disclose pre-certification/second opinion requirements for all plans I subscribe to may  cause me to incur full liability for professional charges because of nonpayment by my carrier. Regardless of insurance benefits, if any, I understand that I am fully responsible for all collection costs, attorney fees and/or court costs. I waive now and forever my right of exemption under the law of the Constitution of the United States. I realize that in extraordinary circumstances, some insurance companies will not pay for certain procedures/treatments. I understand that my insurance is filed as a courtesy and I am responsible for payment of all bills. 

In case of emergency

Patient Information

Consent to Treat

I hereby request and consent to VWC to perform medical/rehabilitative treatment and care as a prescrived by my Physician/CRNP.

I understand and I am informed that the practice of medicine, including physical therpay may have some risks. I understand that I have the right to ask about these risks and have any questions answered about my condition, prior to treatment. 

I authorize the VWC Healthcare provider to perform any additional or different treatment, which is deemed necessary should, during treatment, a condition be discovered which was not known previously. 

I have carefully read and fully understand this Informed Consent Form and have had the opportunity to discuss my condition with the Healthcare Provider. 

I agree to pay all charges submitted by VWC during the course of treatment. I agree to pay all applicable co-payments, co-insurance, and deductibles, which arise during the course of treatment. I also agree to pay for treatment rendered which is not conisdered to be a covered service by my insure and/or thirs-party insurer or other payer. 

 

I further understand that if I do not show for an appointment or do not give 48 hours notice to VWC when cancelling an appointment, I may be responsible for a late charge fee of $25.

FINANCIAL AGREEMENT AND NON-COVERED SERVICES POLICY

 

As a VWC patient, we want to provide you with the best care possible. It is your responsibility to remember to make/ cancel or reschedule your appointment in a timely fashion. We request a minimum of 48 hour notice for any change. We do understand extenuating circumstances may make this impossible and if so, at the discretion of our Healthcare providers may decide to remove the late-notice fee. 

If two (2) or more appointments are missed without proper notice, it is within the right of this office to refuse further service from the practice.

You must notify our offices of the following : name, address, phone number or insurance company change.

HIPAA Acknowledgement and Consent Form 

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIP AA,) I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly. Most specifically to: (1) obtain payment from designated third-party payers, (2) conduct normal health care operations such as quality assessments or evaluations, prior authorizations, and physician certificates.  

By my signature below, I consent to, and acknowledge that Veterans Wellness Center of Alabama may use and disclose my Protected Health Information (PHI) to carry out the following:

Plan and provide for my care and treatment;
Communicate to other healthcare professionals who may contribute or participate in my care and treatment;
Obtain authorization, confirm service provided and collect payment from third party payers; and 
Perform routine healthcare operations such as the review of records from healthcare professionals.

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly. Most specifically to: (1) obtain payment from designated third-party payers, (2) conduct normal health care operation such as quality assessments or evaluations, prior authorizations, and physician certifications. 

I consent and acknowledge that Veterans Wellness Center of Alabama may use and disclose my Protected Health Information (PHI) to carry out the following:

Plan and provide for my care and treatment;
Communicate to other healthcare professionals who may participate in my treatment;
Obtain authorization, confirm services provided and collect payment from third-party payers
Perform routine healthcare operations such as the review of records from healthcare professionals. 

 

I consent to Veterans Wellness Center of Alabama to:

Leave a message at my home, cell or office phone to assist the practice in carrying out routine healthcare operations such as appointments reminders, insurance items and any call pertaining to my clinical care; and
Mail to my home or office any items that assist the practice in carrying out routine healthcare operations such as appointment reminders, test results, patient information forms and patient statements. 

I understand that I have the right:

To request restrictions as to how my Protected Health Information (PHI) may be used or disclosed to carry out treatment, payment or healthcare operations, and that Veterans Wellness Center of Alabama is not required to agree to the restrictions requested;
To review Veterans Wellness Center of Alabama Notice of Privacy Practices, and acknowledge that a copy has been provided to me; and
To revoke this consent in writing, except to the extent that Veterans Wellness Center of Alabama may have already made PHI available to obtain payment from designated third-party payers or conduct normal health care operations prior to this request.

I acknowledge that I have read and understand all the above information.

 

 

Privacy Notice

This Privacy Notice applies to the operations of Veterans Wellness Centers of Alabama (VWC) & our affiliates. 

VWC & our affiliates respect your right to privacy and value the trust you have placed in us. We are committed to the responsible management, use and protection of our customers’ personal information.

This Privacy Notice applies to all the information we collect from you through aline (email/ internet-based), faxes and hardcopy documents.

Consent to Use VWC & our affiliates services

By using VWC and our affiliate’s services you are consenting to the collection, use and disclosure of your personal information in accordance with this Privacy Notice. If you do not agree with the practices described in this Privacy Notice, please do not use VWC & our affiliate’s services.

Information we collect 

Personal information is information that identifies you as an individual or relates to an identifiable person.we collect personal information that you voluntarily provide through our Services, including: 

Name, address, and birthdate; other contact information such as email address and/ or phone number; Financial and health information; Social security or similar national ID number; Geolocation information; and Social media account IDs.

If you submit any personal information relating to other people to us or to our service providers in connection with the Services, you represent that you have the authority to do so and to permit us to use the information in accordance with this Privacy Notice.

Your Personal Health Information

In some circumstances, VWC & our affiliate’s use of your information will also be subject to the requirements of the Health Insurance Portability and Accountability Act (“HIPAA”).

In the circumstances, the terms of VWC’s HIPAA Notice of Privacy Practices will apply.

How We Use Personal Information

We use personal information you provide when you visit or use our Services to fulfill the purpose for which you provide the information and to enhance your experience with us. These uses include: 

Completing transactions, for examples, processing your insurance payments; Processing claims; sending you information about health care and health related services, resources and benefits that will help you manage your health; sending you surveys; Taking any action that we believe to be necessary or appropriate: (a) to investigate, prevent and detect illegal activities; (b) under applicable laws, including laws outside your country of residence; (c) to comply with legal process; (d) to respond to requests from public and government authorities; (e) to enforce out Terms of Service and Privacy Notice; (f) to protect our operations or those of our affiliates; (g) to protect our rights, privacy, safety or property, and/or that of our affiliates, you or others; and (h) to allow us to pursue available remedies or limit the damages that we may sustain; Other purposes specifically is closed at the time we request your information.

How We Share Personal Information 

Sharing Among our Affiliates 

VWC & ou affiliates may share your personal information with one another to ensure that your use of the Services is as helpful and beneficial as possible. We may also share your personal information with affiliates in order to support our business operation, to provide services tp you and for any other purpose described in this Privacy Notice.

Third Party Affiliates

We work with third parties that provide services to us, such as website hosting, data analysis, payment processing order fulfillment, information technology and related infrastructure provision, customer service, email delivery,auditing and other services. We may share your personal information with them so they can provide those services. We will share any personal information you provide on our Services for the purposes stated on the page where we collected the information and in accordance with applicable laws and regulations. We may share with your benefit plan’s plan sponsor or plan administrator the fact that you have visited or used features of our Services to permit your benefit plan’s plan sponsor or plan administrator to determine eligibility, qualification or confirmation of a promised incentive or reward to you 

We may share your information in other limited circumstance, including:

Complying with applicable laws, including laws outside your country of residence; responding to requests from government or public authorities or otherwise cooperating with authorities pursuant to a legal matter, including authorities outside your country of residence; Responding to matters of personal or public safety; In litigation, investigations, and other legal matters where the data is pertinent; Investigating security incidents

Our Data Protection and Security Policy

We take reasonable precautions to safeguard the personal information transmitted between visitors and the Services and the personal information stored on our services. Unfortunately, no method of transmitting or storing data can be guaranteed to be 100% secure. As a result, although we strive to protect your personal information, we cannot ensure the security of any information you transmit to us through, or in connection with, the Services. If you have reason to believe that your interaction with us i no longer secure (for example, if you feel that the security of any account you might ave with us has been compromised), please immediately notify us of the problem by contacting us in accordance with the “Contacting Us” section below.

Our Privacy Commitment to Employment Applicatints: We collect information, including personal contact information, education and work history, as well as social security and similar national ID numbers in order to process and consider your application. We will not sell your application information to unaffiliated third parties for marketing purposes. The information on your application may be shared with background check services and our affiliates and used and disclosed for certain regulatory, compliance and legal purposes.

Social Media

VWC of Alabama maintains profiles and/ or pages on various social media including Facebook and Twitter. If you choose to “Like” VWC on Facebook, and “Follow”  VWC on Twitter, or take any similar action on another social media site, you are providing your consent to receive information updates. To stop receiving this information from VWC on social media site, you must follow the procedure established by the site. 

Changes to this Privacy Notice

We reserve the right to amend this Privacy Notice at any time.

Links to other websites 

The Services contain links to websites operated by third parties. If you provide personal information to any third party’s website, your transaction will occur on that website (not VWC & our affilates) and that operator will collect the personal information you provide, subject to its privacy policies. We encourage you to read the legal notice posted on those sites, including their privacy policies. This Privacy Notice does not apply to your use of and activity on those other websites. We provide links through the services to other websites only as a convenience, and the inclusion of these links does not imply endorsement of the linked site. We have no responsibility or liability for your use of third party websites.

Please note that we are not responsible for the collection, usage and disclosure policies and practices (including the data security practices) of other organizations, such as Facebook, Apple, Google, Microsoft, RIM or any other app developer, app provider, social media platform provider, operating system provider, wireless service provider or device manufacturer, including with respect to any personal information you disclose to other organizations through or in connection with our mobile applications or other websites.

 

REHABA, INC. TeslaMAX TM-4 "Work in Progress"

Electrical Stimulation Equipment Field Beta Test

Home and/or Clinic Use

Patient Informed Consent Form

 

I, the person signing this consent form below, acknowledge that I have been informed that the Tesla MAx TM-4 Electrical Muscle Stimulation device I am to be treated with In-Clinic, or being provided to me for my home use as part of my plan of care ordered by my health care provider, has not yet been cleared by the FDA for marketing in the United States of America. I have been informed that the TeslaMax TM-4 Electrical Stimulation device is a "Work In Progree" not yet granted an FDA 510k Ceritfication of Safety and Effectiveness. If asked, I agree to provide my clinician and/or Rehba, Inc, the manufacturer of the device, with a report as to the results of my treatments with the device sometime later on. I authorize my Doctor to share my treatments esults with Rehba for efficacy documentation, should Rehaba request this information.

I understand that Rehaba will only allow the TeslaMax TM-4 to be used on patients either in-CLinic or for home treatment who have signed this form and are participating in a treatement plan of care like the one ordered by my health care provider. 

The TM-4 made available for my home use and/or treatment in-clinic is provided on loan by Rehaba, Inc., 38954 Proctor Blvd., #158, Sandy, OR 97055, telephone number 702-871-3200. Should I be allowed to take the TeslaMax TM-4 device home with me, I agree to return the device upon demand. 

I agree that I have not been promised any type of guaranteed result, benefit or outcome resulting from my use of or treatment by said "Work In progress" TeslaMax TM-4 device. 

 

Summary: Patient agrees that the use of the loaned "Work In Porgress" FIELD BAETA TESTS TeslaMax TM-4 unit is optional and not required and done at the patient's own risk. Patient acknowledges that unlike Rehaba's other electrical stim devices (such as the TelsaMax TIER4 unit) which are cleared by the FDA as a safe adn effective, the TeslaMax TM-4 unit is not yet cleared for marketing by the FDA and has not yet been found to be safe and effective. 

 

My signtaure below signifies that I have read, Understand and agree to all of the terms regarding my recepit of treatments by the TM-4 as stated above and agree to "Hold Harmless" bothe Rehaba, Inc and the healthcare provider that orginally prescribed home or in-clinic electrical stimulation for me. I willingly and knowingly agree to participate in the filed beta test of said "work in Progress" TM-4 Electircal Muscle Stimulation Device:

Thank you for completing your New Patient Form, we look forward to serving you.