oakwoodvisionservices.com - Patient Record of Disclosures

Patient Record of Disclosures
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home. Be advised that completing preliminary health and insurance questionnaires does not establish a physician-patient relationship with this practice. An initial evaluation is required to determine whether you are a suitable candidate and whether the practice will accept you as a patient.
I wish to be contacted in the following manner (Please check applicable boxes below.)
Cell phone

Leave message with detailed informationLeave message with call back number only
Home phone

Leave message with detailed informationLeave message with call back number only
Written Communication

Mail To My Home AddressMail to my work/office addressFaxOther
Fax to this number
Permission to disclose information form (Please check ONE of the boxes below.)
I allow OakWood Vision Services to discuss my medical information with:I request that my medical information not be shared with anyone other than another medical provider or a pharmacy.
I allow OakWood Vision Services to discuss my medical information with:
By signing this document, I agree to all of the above
Patient Signature: ((If patient is under 18 years of age, a parent or legal guardian must sign.)

Clear
Date

MonthDayYear
Date
Name:
Patient's Birthdate:

MonthDayYear
Date
The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to the uses or disclosures made pursuant to an authorization requested by an individual. Note: Uses and disclosures for TPO may be permitted without prior consent in an emergency.
Record of Disclosures of Protected Health Information

1: Check box if the disclosure is authorized, 2: Type key: T=Treatment Records; P=Payment Information; O=Healthcare Operations; A=Authorization on File; D=Discretionary, 3: Enter how disclosure was made: F=Fax; P=Phone; E=Email; M=Mail; 0=Other

	Date	Disclosed to Whom Address or Fax Number	1	Description or Disclosure/ Purpose of Disclosure	By Whom Disclosed	2	3

	Yes	No
Eczema
Psoriasis
Cancer

	Yes	No
Headaches
Migraines
Seizures
Multiple Sclerosis
Cancer

	Yes	No
Allergies/Hay Fever
Sinus Congestion
Chronic Cough
Dry Throat/Mouth

	Yes	No
Non-insulin Dependent Diabetes
Insulin Dependent Diabetes
Thyroid Dysfunction
Hormonal Dysfunction

	Yes	No
Asthma
Chronic Bronchitis
Emphysema
Cancer

Patient Record of Disclosures

Your Eye Symptoms

Family History

Social History

Flying Hobbies/Recreation/Sport

Patient History Form

Medical History

Patient Registration Form

Personal Information

	Yes	No
High Blood Pressure
High Cholesterol
Stroke
Heart Disease

	Yes	No
Crohn's
Colitis
Ulcer
Digestive

	Yes	No
Drug Allergy
Environmental Allergy
Rheumatoid Arthritis
Lupus

	Yes	No
Depression
Panic Disorder
Schizophrenia