Parham Gharagozlou, MD INC
3108 Willow Pass Rd, Concord, CA 94519
Tel: 9258496634

Patient Consent for Care and Treatment

I have fully read, fully understand, and fully accept the policies of Parham Gharagozlou, MD IC, including the Insurance and Payment Policy, Appointment, No Show and Cancellation Policy, Confidentiality and Privacy Policy (HIPPA Policy)

the undersigned, do hereby give my consent for Parham Gharagozlou, MD and Parham Gharagozlou, MD INC to furnish medical care and treatment to

(Print patient name) that is considered necessary and proper in diagnosing or treating a physical and/or mental condition including diagnostic procedures, surgical and medical treatment and blood transfusions, by authorized members of the office, as may in their professional judgment be necessary."

Signature of Patient or Legal Guardian

HIPPA Policy

Parham Gharagozlou, MD INC Notice of Privacy Practices

Effective Date: 10/1/2010
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.
Parham Gharagozlou, MD Inc. uses health information about you for treatment, to obtain payment for
treatment, for administrative purposes, and to evaluate the quality of care that you receive. Your health
information is contained in a medical record that is the physical property of Parham Gharagozlou, MD
INC.
How Parham Gharagozlou, MD INC. may Use or Disclose Your Health Information
For Treatment. your health information may be used to provide you with medical treatment or services.
For example, information obtained by a health care provider, such as a physician, nurse, or other person
providing health services to you, will record information in your record that is related to your treatment.
This information is necessary for health care providers to determine what treatment you should receive.
Health care providers will also record actions take by them in the course of your treatment and note how
you respond to the actions.
For Payment. Your health information may be used and disclosed to others for purposes of receiving

payment for treatment and services that you receive. For example, a bill may be sent to you or a third-
party payor, such as an insurance company or health plan. The information on the bill may contain

information that identifies you, your diagnosis, and treatment or supplies used in the course of treatment.
For Health Care Operations. Parham Gharagozlou, MD INC may use and disclose health information
about you for operational purposes. For example, your health information may be disclosed to members
of the medical staff, risk or quality improvement personnel, and others to:
 evaluate the performance of our staff;
 assess the quality of care and outcomes in your cases and similar cases;
 learn how to improve our facilities and services; and
 determine how to continually improve the quality and effectiveness of the health care we
provide.

Appointments. Parham Gharagozlou, MD INC may use your information to provide appointment
reminders or information about treatment alternatives or other health-related benefits and services that
may be of interest to the individual.
Required by Law. Parham Gharagozlou, MD INC may use and disclose information about you as
required by law. For example, Parham Gharagozlou, MD INC may disclose information for the following
purposes:

 for judicial and administrative proceedings pursuant to legal authority;
 to report information related to victims of abuse, neglect or domestic violence; and
 to assist law enforcement officials in their law enforcement duties;
Public Health. Your health information may be used or disclosed for public health activities such as
assisting public health authorities or other legal authorities to prevent or control disease, injury, or
disability, or for other health oversight activities.
Decedents. Health Information may be disclosed to funeral directors or coroners to enable them to carry
out their lawful duties.
Organ/Tissue Donation. Your health information may be used or disclosed for cadaveric organ, eye or
tissue donation purposes.
Health and Safety. Your health information may be disclosed to avert a serious threat to the health or
safety of you or any other person pursuant to applicable law.
Government Functions. Specialized government functions such as protection of public officials or
reporting to various branches of the armed services that may require use or disclosure of your health
information.
Workers Compensation. Your health information may be used or disclosed in order to comply with laws
and regulations related to Workers Compensation.

Your Health Information Rights

You have the right to:
 request a restriction on certain uses and disclosures or your information as provided by 45
CFR §164.522; however, Parham Gharagozlou, MD INC is not required to agree to a
requested restriction;
 obtain a paper copy of the notice of information practices upon request;
 inspect and obtain a copy of your health record as provided for in 45 CFR §164.524;
 amend your health record as provided in 45 CFR §164.526;
 request communications of your health information by alternative means or at alternative
locations;
 revoke your authorization to use or disclose health information except to the extent that action
has already been taken; and
 receive an accounting of disclosures made of your health information as provided by 45 CFR
§164.528.

Complaints
You may complain to Parham Gharagozlou, MD INC and to the Department of Health and Human
Services if you believe your privacy rights have been violated. You will not be retaliated against for filing
a complaint.
Obligations of Parham Gharagozlou, MD INC Option:
Care is required to:

 maintain the privacy of protected health information;
 provide you with this notice of its legal duties and privacy practices with respect to your health information;
 abide by the terms of this notice;
 notify you if we are unable to agree to a requested restriction on how your information is used or disclosed;
 accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations; and
 obtain your written authorization to use or disclose your health information for reasons other
than those listed above and permitted under law.

Parham Gharagozlou, MD INC reserves the right to change its information practices and to make the
new provisions effective for all protected health information it maintains. Revised notices will be made
available to you in the manner prescribed in Policy and Procedures.
Contact Information
If you have any questions or complaints, please contact:
Parham Gharagozlou, MD
925 849 6634

Hereby I certify that I read and understood the above privacy information and consent to it.

PATIENT FINANCIAL POLICY

In order to reduce confusion and misunderstanding between our patients and the practice, we have adopted
the following financial policy. If you have any questions, please discuss them with our office staff or billing
department. We are dedicated to providing the best possible care and service to you and regard your complete
understanding of our financial policies as an essential element of your care and treatment. Our financial policy
is:
 Unless you or your insurance company has made other arrangements in advance, payment is due at the time of service. For your convenience, we will accept Personal checks by mail only. Also, most credit cards are accepted.

For payments of more than $250, we do not accept personal checks at this point.

 MEDICARE. We accept assignments on Medicare claims. If you have Medicare, you will be required to pay your 20% co-pay and your deductible or show proof that you have met your deductible at the time of your visit. Please discuss details with our billing office.
 If our physician is not a provider with your insurance company, as a courtesy, we will file your claims for you if you assign benefits to our physician. If your insurance company does not pay within a reasonable time, you will be responsible for payment. We will then provide paperwork to help your insurance company reimburse you.
 If our physician is a provider with your insurance company, we will file your claim, and you will be responsible for deductibles and co-payments at the time of service. If your insurance company states that you did not have coverage for the services rendered at the time of service, you will be responsible
for your balance.
 A charge of $25.00 will be assessed for any returned checks. The patient/guarantor will be held responsible for any collection charges incurred on a delinquent account.
 A $75.00 Charge will be assessed on “no show” for clinic appointments and a charge of $200 on “no shows” for any sleep study. That will be assessed to the patient and not the insurance company. You can not cancel an appointment by claiming you left a message on the answering machine. 

PATIENT RESPONSIBILITY
Unless our contract with your insurance company states otherwise, you will be billed for services designated by your insurance company as patient responsibility.

I have read and understand the financial policy of the practice and I agree to be bound by its terms.