ADONIS PATIENT PROFILE

PATIENT PROFILE

PAGE 1
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Email
Home/Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code

PATIENT PROFILE

PAGE 2
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Age
Employer
Occupation
EMERGENCY CONTACT

Emergency Use Only - CONFIDENTIAL
Emergency Contact

First NameLast Name
Contact Phone
Emergency Contact PhoneFormat: (000) 000-0000.
HIPPA PRIVACY
This HIPPA short form is intended for the use and/or disclosure of Protected Health
Information (PHI) when providing or seeking treatment, payment and healthcare operations.
1. This privacy notice contains a thorough and complete description of the uses and/or disclosures of my Protected Health Information (PHI) which are necessary to provide me with the treatment, and which are also necessary for the practice to obtain payment for that treatment and to perform other healthcare operations. I have been informed that, upon my request, the privacy notice will be made available to me. Prior to signing this Agreement, the Practice advised me of the right to obtain a copy of privacy notice and has encouraged me to read it in it's entirety in accordance with applicable law.
2. To protect your privacy and to remain in compliance with the applicable law, the Practice reserves the right to change the practices depicted in it's Privacy Notice.
3. I am aware of the Practice's Notice of Privacy Practices and I am free to request a copy at any time.
4. The Notice of Privacy Practices contains my rights, as well as the duties and obligations of this office as it relates to my Protected Health Information (PHI).
Full Name

First NameLast Name
Signature

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Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year

HIPAA SHORT FORM NOTICE OF PRIVACY PRACTICES
We understand that health information about you and your health is personal. We are committed to protecting health information about you. We create a record of the care and services that you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by this office, whether made by us or by your personal doctor or others working in this office. This Notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.
We are required by law to:
• Make sure that health information that identifies you is kept private
• Give you this Notice of our legal duties and privacy practices with respect to health information about you; and
• Follow the terms of the Notice that is currently in effect

How we may use and disclose health information about you:
• For treatment
• For payment
• For health care operations
• For appointment reminders
• As required by law
• To avert a serious threat to health and safety
• As required by the Military or Veterans and Worker's Compensation
• Public health risks
• Health oversight activities
• Lawsuits and disputes
• Law enforcement
• Coroners, health examiners and funeral directors
• National Security and Intelligence activities
• Protective Services for the President and others
• Security Officials for inmates

Your rights regarding Health Information about you:
• Right to inspect and copy
• Right to amend
• Right to an accounting of disclosures
• Right to request restrictions
• Right to request confidential communications
• Right to a paper copy of this notice
Changes to this Notice:
We reserve the right to change this Notice. We will post a copy of the current Notice in our facility with the current effective date.

Complaints:
If you believe that your privacy rights have been violated, you may file a complaint with us. All complaints must be in writing. Please contact the administration at the location where you were treated to file a complaint.

Acknowledgment of Receipt of this Notice:
We will request that you sign a separate form acknowledging you have received a copy of this Notice. This acknowledgment will become a part of your records. This acknowledgment provides that you have declined to accept the complete notice and requested the short form. We post a copy of the current complete Notice of Private Practices in our facility, on our website at website address: www.AdonisMedicalClinic.com and you may also ask for a copy.

Current copy date: Oct. 2023
Signature
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
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